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ARMY MEDICAL LIBRARY
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Founded 1836
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Number .J.7S..^.k..k
Fobm 113c, W. D., S. G. O.
(Revised June 13, 1036)
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70
PRINCIPLES
SURGERY.
By the same Author.
THE PRACTICE OF SURGERY,
IN ONE OCTAVO VOLUME.
THE
PRINCIPLES
S II E G E R I,
BY
JAMES MJJJJER, F.R.S.E., F.R.C.S.E.,
PROFESSOR OF SURGERY IN THE UNIVERSITY OF EDINBURGH J SURGEON TO THE ROYAL INFIRMARY,
ETC. ETC.
SECOND AMERICAN EDITION.
LI BR Aft V
oURGEON GENERAL'S OFFICE
JAH.-15.-1902
PHILADELPHIA:
LEA AND BLANCHARD
1848
/
V/0
9 4-
DEDICATED TO
EOBERT LISTON;
AS A TRIBUTE OF RESPECT,
TO THE
DISTINGUISHED RANK WHICH HE SO JUSTLY HOLDS
AMONG THE SURGEONS OF EUROPE;
AND IN GRATEFUL ACKNOWLEDGMENT
OF MUCH PERSONAL KINDNESS,
AS WELL AS PROFESSIONAL INSTRUCTION,
CONFERRED ON
THE AUTHOR.
1*
P E E E A C E.
The following pages, intended to exhibit a condensed view of the
Principles of the Healing Art, contain the substance of the Author's
systematic Lectures on this subject'. In their preparation, it has been
his aim to combine, with soundness of doctrine, such simplicity of
arrangement and plainness of illustration as seem best calculated to
facilitate, while they direct, the labours of the student.
To his own Pupils, the Volume is offered as one of reference as
well as a text-book; and he ventures to hope that, to others also,
it may prove of service, as a concise exposition of the Science of
Modern Surgery.
CONTENTS.
SECTION I.
ELEMENTARY DISEASE.
CHAPTER I.
PERVERTED ACTION OF THE BLOOD-VESSELS.
Inflammation,
Congestion, - -
CHAPTER II.
PERVERTED ACTION OF THE NERVES.
Irritation,
Irritation, Local, -
Irritation, Constitutional,
The Shock of Injury,
CHAPTER III.
PERVERTED ACTIONS OF THE ABSORBENTS.
Atrophy,
Interstitial Absorption, -
Continuous Absorption,
CHAPTER IV.
SUPPURATION,
Acute Abscess, -
Chronic Abscess, -
Diffuse Abscess,
Scrofula,
CHAPTER V.
ULCERATION,
Granulation, - -
Cicatrization, -
Ulcers,
X
CONTENTS.
CHAPTER VI.
MORTIFICATION,
Articular Ulcer and Caries, -
Resection of Joints,
PACE
203
SECTION II.
PERVERTED VASCULAR ACTION IN CERTAIN TISSUES.
CHAPTER VII.
PERVERTED VASCULAR ACTION IN THE INTEGUMENTS, - 219
"Erythema, --------- 219
Erysipelas, ------- - 220
Hospital Sore, -------- 232
Furunculus, -------- 235
Anthrax, --------- 236
Diffuse Cellular Infiltration, ------ 238
CHAPTER VIII.
PERVERTED VASCULAR ACTION OCCURRING IN BONE, - 239
Periostitis, --------- 239
Ostitis, --------- 214
Suppuration of Bone, ----... 245
Absorption of Bone, - - - - - - - 251
Ulceration of Bone, -.__.__ 252
Caries, -------.. 253
Necrosis, --------- 259
Fragilitas Ostium, ------- 274
Mollities Ossium, -----.._ 275
Rickets, -------- 276
CHAPTER IX.
DISEASES OF THE JOINTS, - - - 280
Synovitis, Acute, - - - - - . . -281
Synovitis, Chronic, - . 285
Synovitis, Chronic, Scrofulous, ---... 288
Brown Intractable Degeneration, - 290
Fimbriated Synovial Membrane, - - - . . - 291
Inflammatory Process Exterior to Joints. - 292
Tophi, "-------. 293
Destruction of Cartilage, ------ 294
Hypertrophy of Cartilage, -•---.. 30g
Atrophy of Cartilage, -----.. q06
Porcellanous Deposit, ---_.. o07
Osseous Deposit, Exterior to the Ariiculation, - 3o7
Interstitial Absorption of Bone, implicating the Joint, - 30o
Loose Cartilages in the Joints, ---.._ „"
312
313
Anchylosis,
Neuralgia of Joints. ------. t~
■Wounds of Joints, -----.. t\a
Affeclicm of Bursa, - *°
Affections of Thecce, ----.. 3l9
M J , " - 321
CONTENTS.
XI
CHAPTER X.
DISEASES OF THE ARTERIES.
PAGE
Arteritis, Acute, -------- 323
Arteritis, Chronic, - - . - - - - - 325
Aneurism, --------- 326
Aneurism by Anastomosis, ------ 356
Arterial Varix, -------- 360
CHAPTER XI.
AFFECTIONS OF VEINS.
Phlebitis, - - - - - - - - - 361
Varix, --------- 36.')
Entrance of Air into Veins, - - - - - - 369
CHAPTER XII.
HEMORRHAGE, - 372
Arterial Hemorrhage, - - - - - - - 3?2
Venous Hemorrhage, _.----- 384
The Hemorrhagic Diathesis, ------ 385
CHAPTER XIII.
AFFECTIONS OF THE LYMPHATICS, - - - 389
Angeioleucitis, -------- 389
Inflammatory Swelling of Lymphatic Ganglia, - - - - 391
Tumours of Lymphatic Ganglia, .... - 392
CHAPTER XIV.
AFFECTIONS OF NERVES, - 393
Neuritis,........393
Neuralgia, --------- ^^
SECTION III.-
PERVERTED NUTRITION.
CHAPTER XV.
TUMOURS, - - - - 398
Benign Tumours, ------ 404
Malignant Tumours, ----- "490
Encysted Tumours, ------ 4^j
Tumours of the Integument, ... - - 431
Tumours of Mucous Membrane, ... - 4d^
Tumours of Nerve, ----- - 434
Tumours of Bone, ----- 4™
Xll
CONTENTS.
SECTION IV.
INJURIES.
CHAPTER XVI.
PAGE
444
wounds, - - ^y*
Incised Wounds, - - - -
Contused and Lacerated Wounds, - " " 460
Punctured Wounds, - 4(..
Poisoned Wounds, - .j^
Gunshot Wounds, ... -
Subcutaneous Wounds, - " .„„
Tetanus, - - - - -
CHAPTER XVII.
BURNS AND SCALDS,
CHAPTER XVIII.
THE EFFECTS OF COLD, -
CHAPTER XIX.
FRACTURE, - " * - 497
Compound Fracture, ------- 510
Ununited and Disunited Fracture, - - - - - - 513
489
496
CHAPTER XX.
DISLOCATION, - - - 516
Compound Dislocation, ------- 523
Subluxation, --------- 525
CHAPTER XXI.
SPRAIN, AND RUPTURE OF MUSCLE AND TENDON, - - 526
CHAPTER XXII.
BRUISE, - 529
SURGERY.
HISTORICAL NOTICE.*
The term Surgery, or Chirurgery, from x€tP, the hand, and epyw,
work, originally, signified, as its derivation implies, the manual pro-
cedure, by means of instruments or otherwise, directed towards the
repair of injury and the cure of disease; in contradistinction to the
practice of medicine, which denotes the treatment of disease by the
administration of drugs, or other substances supposed to be of a sana-
tive tendency. Such a meagre description applied but too justly to
surgery in its infancy, and still more after its separation from its twin-
sister medicine, in the twelfth century. When its practice was de-
nounced by the Council of Tours as derogatory to the dignity of the
sacred office of the priesthood, and beneath the attention of all men
of learning, the term chirurgery, in its most literal interpretation, was
quite sufficient to comprehend the duties of the degraded and unin-
formed surgeon, who had degenerated into a mere mechanic, attached
to, and completely dependent on, the learned and philosophic physi-
cian. But the matured progress of the healing art, fortunately for
science and humanity, has rendered such a definition of surgery in
these days utterly untenable. Its complete separation from medicine
would not be attended with the utmost difficulty; nor is it desirable
that the attempt should be made, because its success, however partial
and imperfect, Avould be most hurtful to both. They are now, and it
is to be hoped will ever remain, one and inseparable. Their prin-
ciples are the same throughout, and the exercise of their different
branches requires the same fundamental knowledge ; but their details
are so numerous and intricate as to render it most difficult, if not
impossible, for any one individual to cultivate all with equal success.
The consequence has been, that while the theory and principles of
physic and surgery remain united, as constituting one. and the same
science, the practical parts are now frequently separated into distinct
professions, each person adopting that department most congenial to
his pursuits, and for the management of which he conceives himself
best qualified. The separation, however, is not one of acquirements,
but merely of practice. It should never be forgotten, that the physi-
cian, before he can be either accomplished or successful in his pro-
fession, must be intimately conversant with the principles, if not
• This condensed view of the History of Surgery was written by the Author ft
the last edition of the Encyclopedia Brittanica, and is here reprinted by the kin
permission of the Proprietors.
2£
HISTORICAL NOTICE.
with the practice of surgery. And most certainly, no one can ever
lay just claim even to the title of surgeon, far less hope for eminence
or success, unless he be equally qualified to assume both the appella-
tion and the employment of the physician.
Many and laboured have been the attempts to define surgery
according to its present state, so as to prevent interference with the
department of physic. This example we will not follow. The
arrangement as to what is medical, and what surgical, must, in a
great measure, depend on custom, not on fixed and permanent rules.
The paths of the practical surgeon and physician are distinct, but in
their course they must often cross each other; and these collisions, so
far from being avoided, ought rather to be sought, as probable sources
of mutual benefit, so long as those enlightened feelings are entertained,
and that honorable conduct pursued, which ought ever to distinguish
the followers of a liberal, useful, and learned profession.
That surgery is as old as man himself, that it was coeval with his
fallen state, there can be little doubt. The fall entailed the frequent
reception of injuries by external violence; and to assuage their pain
and remove their inconvenience, the ingenuity and contrivance of the
sufferer were, doubtless, powerfully excited. Thus it would seem that,
as to antiquity of origin, surgery must take precedence of medicine.
And after wars and dissensions began to prevail, and wounds and inju-
ries became both more frequent and more deadly, it is most probable
that to these the practitioners of the healing art alone directed their
attention, before the nature of disease began to be understood, or its
cure was supposed to be within the reach of human means.
As to the state of surgery among the early Egyptians, we know but
little, except that it was customary, in the time of Joseph, to embalm the
dead—a process which appertains closely to both medicine and surgery.
There are some grounds, however, for suspecting that they were more
conversant with surgery than is generally supposed ; for it is said that on
" the ruined walls of the renowned temples of ancient Thebes, basso-
relievos have been found, displaying surgical operations, and instru-
ments not far different from some in use in modern times." Their
medical practice, entirely founded on incantation and astrology, was
sufficiently simple. They divided the body into thirty-six parts, be-
lieving in an equal number of demons, to whom those parts were
intrusted, and to invoke whose aid in sickness was the principal duty
of the physician, each spirit being called upon to cure his own peculiar
portion.
Among the Jews, the operation of circumcision was performed, no
doubt skilfully and dexterously, though Avith rude implements, by the
priesthood, an order which, for many ages, and in many climes, con-
joined the cure of the body with that of the soul.
The earliest notice of our art is from the ancient Greeks, who, it is
probable, had derived their medical traditions from the Egyptians.
They considered medicine to be of Divine origin ; and its first profess
sors, as they inform us, were no less personages than gods and sons of
gods.
Medicine and surgery, at their origin, were conjoined ; and both
HISTORICAL NOTICE.
27
continued to be practised indiscriminately, until separated by the Ara-
bian school. Their complete estrangement occurred, as we have
already stated, about the middle of the twelfth century. At first, sur-
gery chiefly occupied the attention of the ancient leech, as the more
certain and more obviously useful branch of his profession; but ulti-
mately it became very secondary to medicine when dignified by phi-
losophy and priestcraft.
Chiron the Centaur, born in Thessaly, is presumed to have been the
father of surgery, celebrated for skilfully applying soothing herbs to
wounds and bruises. But his fame is somewhat endangered by that of
iEsculapius, the son of Apollo, by some held to bo the pupil of Chiron,
by others, his predecessor and superior. iEsculapius is supposed to
have been deified, on account of his skill, about fifty years before the
Trojan war. His very existence, however, has been questioned.
Apollo was the original god of physic among the early Greeks ; but he
appears to have resigned in favour of iEsculapius, whose temples
became the depositories of medical and surgical knowledge; more
particularly those of Epidaurus, Cnidos, Cos, and Pergamus.
Certain it is, according to the testimony of Celsus, that iEsculapius is
the most ancient authority in surgery. His immediate descendants,
two sons, Podalirius and Machaon, have been immortalized by Ho-
mer. They followed Agamemnon to the Trojan war (b. c. 1192,) and
there their services were so highly valued as to secure them a not
unconspicuous niche among the heroes of the Iliad. Of the two,
Machaon seems to have been the more distinguished. When he is
wounded by Paris, the Avhole army is represented as interested in his
recovery. Even the stern Achilles inquires anxiously after " the
wounded offspring of the healing god ;" and the valiant Nestor, to
whose care he is intrusted, is exhorted to unwonted exertion in his
behalf; " for a leech who, like him, knows how to cut out darts, and
relieve the smarting of wounds by soothing unguents, is to armies
more in value than many other heroes." Podalirius enjoys the dis-
tinction of being reputed the first of phlebotomists, and probably the
most successful, from his time to this; having opened a vein in either
arm of the King of Caria's daughter, who had been severely injured
by a fall from the house-top; having, after her recovery, been re-
warded with the hand of the fair princess; and having been presented
by her munificent father with the Chersonese as her dowry. As to
medicine, they seem to have been either ignorant, or in no great
repute ; for, on the breaking out of pestilence in the Grecian camp,
Homer neglects them entirely, and applies at once to Apollo. And
even their surgical attainments, for which they are celebrated by him,
seem to have extended no farther than to the simple extraction of
darts and other offensive weapons, the checking of hemorrhage by
styptics or pressure, and the application of lenitive salves. The poet
takes notice of his warriors sustaining fracture of the bones; but in
such emergencies he adopts the same course as in the pestilence, and
invokes the aid of the non-proiessional deities; from which circum-
stance we may infer, that in those days surgery had made but little
advancement.
For upwards of 600 years after the Trojan war, there are scarcely
28
HISTORICAL notice.
any accounts of medicine and surgery. They Seem to have renamed
stiangely stationary during the whole of that period aiieir practice
was confined to the Asclepiades, or reputed descendants of iEsculapius;
whose lore was orally communicated from father to son in that family,
until they received an extraordinary impulse from the great Hippocrates,
himself a branch of the family, and said to have been the fifteenth in
lineal descent from the deified founder. The Asclepiades, in the course
of their monopoly, established three schools of medicine, at Rhodes, at
Cnidos, and at Cos. The last gave Hippocrates to the world, and thus
attained a proud and enduring pre-eminence.
Pythagoras (b. c. 600) was the first who brought philosophy to bear
upon the°practice of the healing art, and led the way in raising it to the
dignity of a science. Democritus, the happy sage, likewise turned his
attention to medicine as a branch of general philosophy, and pursued
it zealously. He lived in terms of friendship with Hippocrates, by
whom he was held in great respect. By Pythagoras a school at Cro-
tona was founded, about the time of Tarquinius Superbus, espousing
doctrines somewhat different from those of Cos and Cnidos. It pro-
duced Damocedes, a contemporary of Pythagoras, who seems to have
practised in Athens, an honoured and successful surgeon. By Poly-
crates, king of Samos, he was presented with two talents of gold for
having cured him of a troublesome distemper. He was afterwards
taken captive by the Persians. Their king, Darius, was intrusted to
his care for a dislocated ankle, as well as the queen, Atossa, for a can-
cer of the breast; and he was soon loaded with honour and wealth, on
account of his wonderful cures, performed after the Egyptian physicians,
previously in attendance, had signally failed.
But we cannot suppose such men as Damocedes and the Asclepiades
to have attained any great proficiency in surgery; for the touch of a
dead body was interdicted as a profanation both by Jew and Greek,
and consequently they must have been almost entirely ignorant of
anatomy. They may have understood something of the skeleton, from
their practice among fractures and dislocations; and they may have
formed some general idea of the viscera, from researches in compara-
tive anatomy, and from instruction by the Egyptians, whose prac-
tice in embalming afforded ampler scope for observation. But the
minute structure of the human body must have been to them a profound
mystery. And, knowing that anatomy is, was, and ever must be, the
foundation of true surgical knowledge, we cannot evade the conviction
that surgery, though occasionally successful and honoured in ancient
times, must have been nothing more than a rude, imperfect and uncer-
tain art. The practice of its professors seems to have been extremely
limited, consisting of little more than the binding up of wounds, and
the staunching of hemorrhage by styptics and the cautery ; the extrac-
tion of darts and other missiles from the wounds which they had inflicted •
phlebotomy, both general and local; and cupping by scarification.
Whether they practised the capital operations or not, we are not in-
formed ; but it is probable that their comparative ignorance of anatomy
effectually deterred them from any extensive division of the soft parts
as extremely hazardous and uncertain.
Hippocrates, born in the 80th Olympiad, upwards of 400 years be-
HISTORICAL NOTICE.
29
fore the Christian era, did more for medicine and surgery than all who
had preceded him ; and indeed few of those who have come after have
been of equal service to the profession. He soon freed medicine in a
great measure from the absurdities with which ignorance and supersti-
tion had invested it; and through a long, honoured, and glorious life
he set a splendid example of persevering industry, philosophical re-
search, and high moral worth. His fame soon raised the Coan school
far above its rivals. Though his anatomical knowledge seems little
better than a blending of ingenuity with error, yet he appears to have
had some indistinct notions of the circulation of the blood; although
Dr. Pitcairne, in his " Solutio Problematis de Inventoribus," has suffi-
ciently evinced that he was very far from anticipating the great disco-
very of Harvey. With all his deficiencies, and notwithstanding all the
disadvantages under which he laboured, so correct was his observation,
and so faithful his chronicling of disease, that many of his descriptions
may be fairly inserted in our modern nosologies. Though his atten-
tion was chiefly directed towards the improvement and promotion of
physic, now begirt with philosophy, and studied as a science, and
though his practice was principally confined to the treatment of internal
disease, yet he was not wholly inattentive to surgery. And his prac-
tice seems to have been tolerably bold and decisive ; for, in regard to
external disease, it was with him a maxim, that " when medicine failed,
recourse should be had to the knife, and when the knife was unsuc-
cessful, to fire ;" a remedy of which all the ancient doctors seems to
have been particularly fond, from Prometheus downwards. Hippo-
crates employed it not only in a variety of diseases, but in various forms.
Sometimes he applied red-hot irons to the part; sometimes he raised
a conflagration on it, and of it, by a piece of wood dipped in boiling
oil or by burning a roll of flax after the manner of the modern moxa.
He also made use of tents and issues, as more gentle means of counter-
irritation. He seems to have performed the capital operations with
boldness and success, excepting lithotomy, the practice of which ap-
pears to have been confined to a few who made it their exclusive study.
He however, recommends the removal of calculus, large and firmly
lodged in the kidney, by incision ; adding, probably in apology for the
dartno- of the procedure, that otherwise there arc no hopes of a cure,
and that the disease must prove fatal. He reduced dislocations, and
set fractures, but clumsily and cruelly ; extracted the foetus with forceps
when necessary; and both used and abused the trepan, employing it
not only in depression and other accidents of the cranium, but also in
cases of headach, and other affections, to which the operation was in-
applicable. In cases of empyema and hydrothorax, after ascertaining
by percussion that fluid was present in the cavity of the chest, he did
not hesitate to make an incision between the ribs ; and having allowed
part of the fluid to escape, he placed a tent in the wound, and by with-
drawing it regularly once a day, the whole was ultimately evacuated.
He seems to have been perfectly acquainted with tetanus and sponta-
neous gangrene; observing, that even minute wounds of tendinous
parts', as the fingers and toes, sometimes produce convulsions which
terminate fatally! and that black spots on the feet frequently increase
a*
30
HISTORICAL NOTICE.
to extensive gangrene and incurable mortifications. Some of his prac-
tices have been long and justly exploded, some have been successfully
continued, and others have, after disuse, been revived as modern in-
ventions. For example, his method of ascertaining the presence or
absence of fluid in the chest was by percussion, and applying the ear to
the part, thus foreshadowing the use of the modern stethoscope. One
of his modes of counter-irritation, we have seen, was by buring flax on
the part, as in the modern moxa ; and he strongly recommends the pro-
duction of eschars on the back and breast in the earliest stages of pulmo-
nary disease, thus anticipating the supposed valuable discoveries of a
celebrated modern charlatan. His writings are elegant, and well repay
a careful perusal. By them he made posterity his debtor. Plis contem-
poraries were not insensible to his merits, and endeavored to reward
them during his life. The inhabitants of Argos voted him a statue of
gold ; he was more than once crowned by the Athenians, and, though
a stranger, was initiated into the most sacred mysteries of their religion,
the highest distinction which they could confer ; after his death, uni-
versal and almost divine honours were paid to his memory; temples
were erected to him, and his altars covered with offerings.
We have already seen that surgery had long been stationary before
the time of Hippocrates ; and it made but little advancement during
many succeeding generations. The Asclepiades had confined the
knowledge of medicine among themselves; Hippocrates, however,
gave oral instructions in anatomy and the art of healing, and thus dis-
closed its mysteries to the world. But few of his disciples seem to
have profited much by his liberality. One of them, his kinsman Ctesias,
we are told, acquired considerable renown for his skill; and having
been taken prisoner by Artaxerxes Mnemon, in a battle fought against
his brother Cyrus, was successful in curing him of a severe wound, and
thus obtained favour with his captor. Plato began to flourish about
this time (b. c. 370 ;) but though he was connected with medicine, we
cannot lay claim to him as eminent in surgery; and he was more famous
for his philosophy than his physic. Perhaps the most distinguished in
surgery, among the more immediate successors of Hippocrates, was
Diodes Carystus. He devoted more attention to anatomy than any of
his predecessors, was curious in bandaging wounds of the head, and
invented the bellulon, an instrument for extracting darts. Carrying
his surgery into the practice of medicine, he was not very happy in the
result: from observing that external wounds, abscesses, and inflamma-
tions were attended with fever, he supposed that general fever was
uniformly occasioned by one or more of these causes operating inter-
nally. He followed Hippocrates in practice, and, like him, cuftivated
his profession, « not for lucre or vainglory, but from real love of the
medical art, and a pure spirit of humanity." Praxagoras of Cos was
the last of the Asclepiades who succeeded in leaving a name behind
him. As a surgeon he is reported to have been bold in the extreme,
incising the fauces freely, and excising portions of the soft palate in
bad cases of cynanche ; and making incisions into the bowels to remove
obstructions when milder measures failed. He is said to have been
the first to distinguish between arteries and veins, and to observe the
HISTORICAL NOTICE.
31
pulse as an index of the general system. Aristotle, the celebrated pre-
ceptor of Alexander the Great, although not strictly in the medical pro-
fession, was the promulgator of doctrines which for a long time had a
powerful effect on medicine. While he followed out the general prin-
ciples of the healing art, and was curious in anatomical research, giving
the aorta its name, and showing that all blood-vessels centre in the
heart—he seems to have disdained to meddle with the practical details,
and among the rest those of surgery.
On the dismemberment of the vast empire of Macedonia after the
death of Alexander the Great, learning took up its chief abode at Alex-
andria, under the protection of Ptolmey Soter, (b. c. 300.) And here
it was that popular prejudice first gave way, and permitted the exami-
nation of dead bodies, the greatest possible boon to the medical pro-
fession, inasmuch as it removed what had hitherto been the most
serious obstacles to its advancement, ignorance of human anatomy.
Herophilus and Erasistratus, the two great heads of the Egyptian
medical school, were the first who had an opportunity of practising
human dissection, the bodies of criminals having been given to them
for that purpose ; and they consequently, not only corrected many
errors, but made numerous and important discoveries in anatomy ; thus
imparting a fresh stimulus, and affording a new and more solid basis
to both medicine and surgery. By some they have been accused of
carrying their enthusiasm in this inquiry to such an extent as to " open
the bodies of living criminals for the furtherance of their physiological
views;" this, however, is probably a mere exaggeration, originating
in the horror Avith which human dissection was at first regarded.
But we find even these privileged men falling into most palpable mis-
takes ; for example, Herophilus plainly confounds the tendons and liga-
ments with the nerves. Yet the fact.that the names which he gave to
many parts still remain in use, will of itself remind posterity how much
they are indebted to him for his anatomical labours. He was like-
wise one of the greatest surgeons of ancient times, and, as well as
Erasistratus, acquired as much fame for brilliant cures as for anato-
mical knowledge. The surgical practice of the latter was character-
ized by peculiar boldness and decision, and strongly marked with the
failing of his time and school, a love of multiplying and inventing mur-
derous implements, and the relentless use of them. " In schirrosities
and tumours of the liver, he did not scruple to make an ample division
of the integuments, and try applications to that viscus itself. He fol-
lowed the same practice in diseases of the spleen, which he regarded
as of little consequence in the animal economy." And perhaps he
was right in his supposition, though not in his practice. In cases of
retention of urine, he made use of the particular catheter which long
bore his name. Xenophen of Cos, said to have been a follower of
Erasistratus, seems to have been among the first who arrested hemor-
rhage from a member, by encircling it tightly with a ligature. Man-
tius, a pupil of Herophilus, wrote a treatise on surgical dressings,
which he rendered complicated in the extreme. Another, Andreas of
Carystus, wrote on the union of fractured bones, and invented several
ponderous machines for reducing luxations of the femur. Indeed, the
32
HISTORICAL N OTICE.
surgeons of the Alexandrian school were all distinguished by the nicety
and complexity of their dressings and bandagings, of which they in-
vented a great variety. Among them, as in the time of Hippocrates,
lithotomy was practised by particular individuals, who devoted them-
selves exclusively to that operation ; and we are told thatone of them,
Ammonius, employed an instrument, by means of which he broke
down stones in the bladder, plainly anticipating Civiale, and furnish-
ing a marked example to the present age of the truth of Solomon's
apophthegm, that " there is nothing new under the sun."* It is not
improbable that some of their other practices might have afforded
equally striking examples of this sometimes unpalatable truth; but
unfortunately the greater part of .the writings of the Alexandrian
school perished in the conflagration of the famous national library in
the time of Julius Cgesar; a calamity fraught with immense loss to the
healing art, as well as to almost every other branch of knowledge.
The arts and sciences followed the seat of empire in its transfer to
Europe under Julius Cicsar, and Rome became the grand centre of in-
tellectual illumination. Notwithstanding the shrewd sense displayed
by the ancient Romans inmost matters, it is strange, yet true, that for
centuries all ranks of society, from the mere plebeian rabble to the cen-
sor, had entertained an abhorrence of all practitioners of medicine
and surgery, and trusted for cures to spells and incantations. Indeed,
public edicts were issued, " discouraging all countenance to the pro-
fessed exercise of physic, and recommending faith in traditionary pre-
scriptions and religious rites." Cato the censor managed the sick of
his own family according to the terms of this edict, and gravely wrote
down the words of incantation for curing dislocation or fracture. For
nearly the first six hundred years of its existence, Rome, accordingly,
had no regular practitioner of medicine. The first we read of was
Archagathus, a Greek, from the Alexandrian school, who practised in
Rome, chiefly as a surgeon, daring the consulates of Lucius iEmilius
and Marcus Livius. At first his surgical skill obtained for him no in-
considerable fame, but the ancient prejudice soon revived in full vi-
gour. An enraged populace—perhaps not without some reason, for
he seems to have been particularly fond of the knife and cautery—com-
pelled him not only to suspend his practice, but, changing his original
title of " healer of wounds" to that of " executioner," caused him to
be banished from the Roman capital. Afterwards, however, a native
of Bithynia, assuming the name of Asclepiades (b. c. 96,) established
himself in tolerable repute, by virtue of insinuating manners, shrewd
common sense, and the performance of several fortunate cures " tuto,
cito, et jucunde." But with him we have little concern, for his saga-
*A curious illustration of this is given by Dr. James Johnson, in the narrative of his
visit to Pompeii. " The Dilator or Speculum, for which Mr. Weiss of the Strand ob-
tained so much repute a few years ago, has its exact prototype in the Bourbon Museum
at Naples. The coincidence in such an ingenious contrivance would be absolutely
miraculous; but unfortunately there is a key to the similitude, which destroys the
charm of astonishment. A crafty Frenchman imitated from memory, and with some
awkward deviations, the Pompeian Speculum, and passed it off as his own. Weiss
improved upon the Frenchman, and hit upon the exact construction of the orig-
inal ! Many modern discoveries may probably have originated in the same way "°
HISTORICAL NOTICE.
33
city soon taught him that it was essential to his welfare to avoid the
unpopular practice of surgical operations, and, accordingly, he con-
fined himself entirely to the apparently less hurtful administration of
medicine. The only important traces of his surgical practice are, that
in ascites he practised and recommended discharge of the accumulated
fluid by minute punctures of the abdominal parietes; and that for
quinsy, which term probably comprehended many of the various acute
diseases of the throat now known and distinguished, he not only em-
ployed bold blood-letting, local and general, by the lancet and by cup-
ping, but also had recourse to scarification of the fauces, and even
attempted laryngotomy. By novel and successful cures in his medical
practice, and frequent indulgence in skilful quackery, he obtained great
personal reputation, and so far overcame popular prejudice as to es-
tablish a tolerably fair field in Rome for future practitioners. He was
the contemporary of Caesar, and the personal friend of Cicero. The
latter is eloquent in his praise, and through him seems to have formed
a high estimate of the medical character. " Nothing," says he,
" brings men nearer to the gods, than by giving health to their fellow-
creatures." It Avould thus seem that, in his time at least, the ancient
grudge against the doctors had abated in Rome. Among the disciples
and immediate followers of Asclepiades was Cassius, described as
Iatro-Sophista, who left behind him several works on anatomical and
surgical subjects. In one of the latter he distinctly accounts for inju-
ries on one side of the head producing paralysis on the other, from
the decussation of the nervous fibres ; a tolerable proof that he was
not only a good anatomist for the time, but also an observant prac-
titioner.
Rome itself did not produce a single medical practitioner of any
reputation before the age of Aulus Cornelius Celsus, although he him-
self chooses to be complimentary to some of his immediate prede-
cessors, " Tryphon, Euelpistus, and Meges, the most learned of them
all." Celsus, the contemporary of Horace, Virgil, and Ovid, likened
to Hippocrates for the quantity of his sound practical information, and
to Cicero for the elegance of his style, lived in the reigns of Tiberius,
Caligula, Claudius, and Nero, in the beginning of the first century of
Christianity, upwards of a hundred and fifty years before Galen.* In
his celebrated medical work, he places great reliance on Hippocrates
and Asclepiades, more particularly the latter, and gives a complete and
excellent digest of all the true medical and surgical knoAvledge of his
times, although it is not certain that he himself either practised medi-
cine or operated in surgery. " Of his surgical operations and remarks,
many are yet far from being obsolete, and impress us with a high idea
of his ingenuity and judgment. His mode of performing lithotomy (on
* A life of Celsus by Joannes Rhodius is subjoined to a second edition of a work of
that learned Dane, entitled " De Acia Dissertatio, ad Corneiii Celsi mentem, qua simul
uni versa Fibulae ratio explicatur." Hafniae, 1672, 4to. We must likevx ise refer our
philological readers to " Jo. Baptistas Morgagni in Aur. Corn. Celsum et CI. Ser. Sam-
onicum Epistolse, in quibus de utriusque Auctoris variis Editionibus, Libris quoque
manuscripts, et Commentatoribus disseritur." Ilagse Com. 1724,4to. The prae-
nomen of Celsus appears to have been Aulus, and not Aurelius, which is a" nomen
gentile." See Fabricii liibliotheca Latina, torn, ii., p. 37, edit. Ernesti.
34
HISTORICAL NOTICE.
the gripe) has been in recent times warmly defended by Heistcr, espe-
cially as applicable to children. He describes the operation for cata-
ract"by depression, and the method of forming an artificial pupil. ^ Ihe
whole of his account of injuries of the head is admirable, and evinces
wonderful tact and discrimination. His rules for distinguishing^frac-
ture, and for the application of the trepan, have been highly eulogized ;
nor is what he says about contrecoups less accurate. He is the first
who has remarked that there may be rupture of a vessel within the
cranium without fracture or depression." And he is the first who re-
commended the application of ligatures to a wounded artery, with the
view of arresting its hemorrhage, after pressure has failed. He im-
proved amputation, an operation then not much in use ; and recom-
mended its adoption in cases of gangrene from external causes. He is
minute in his details as to the treatment of fracture and dislocation ; his
description of carbuncle is good, and its treatment similar to that now
pursued, namely, free application of the strongest escharotics to the
gangrened part. He describes several species of hernia, and gives di-
rections for their reduction ; and also mentions the operation of hare-lip.
" It would be endless, however, to particularize. Whoever wishes to
know the exact state of surgical knowledge in the world at the time of
the Caesars, may turn to the pages of Celsus, with the hopes of a grati-
fication which will not be disappointed."
He relates an interesting anecdote of Hippocrates, illustrative of his
abuse of the trepan. " Knowing and skilful as he was, he once mis-
took a fracture of the skull for a natural suture ; and was afterwards so
ingenuous as to.confess his mistake, and leave it on record." To this he
adds, " This was acting like a truly great man: little geniuses, con-
scious to themselves that they have nothing to spare, cannot bear the
least diminution of their prerogative, nor suffer themselves to depart
from any opinion which they have embraced, how false and pernicious
soever that opinion may be ; while the man of real ability is always
ready to make a frank acknowledgment of his errors, especially in a
profession Avhere it is of importance to posterity to read the truth;" a
moral which cannot be too often forced upon our attention.
Aretaeus, born in Cappadocia, practised in Rome, probably about the
time of Domitian (a. d. 50-80,) He was the first who made use of
blisters, using cantharides for that purpose. He brought the operation
of bronchotomy into disuse ; conceiving that the untoward symptoms of
suffocation were increased thereby, and that the wound was incapable
of healing. ^ Dissection in his time was prohibited under the severest
penalties : his anatomical knowledge was therefore neither profound nor
exact; " nevertheless he had the sound penetration to regard anatomy
as the only legitimate basis on which either medical or surgical science
could rest." Rufus, the Ephesian, who seems to have lived in the
time of the Emperor Trajan, (a. d. 96-117,) was a zealous anatomist and
surgeon, and has left a treatise on diseases of the kidneys and bladder.
He tied an artery which had been wounded in venesection, and be-
come aneurismal, at the bend -of the arm. From the time of Celsus
the aneurismal formations, if treated at all, had hitherto been attacked
exclusively by incision, and the actual cautery. Heliodorus, the cele-
HISTORICAL NOTICE.
35
brated physician of Trajan, has left some excellent observations on in-
juries of the head. Antyllus, by some said to have been almost a contem-
porary, by others not to have flourished till A. d. 340, was a zealous and
successful surgeon. He boldly recommends bronchotomy in cases of
threatened suffocation induced by disease of the throat, and, in inflam-
matory affections of emergency, advises arteriotomy in preference to
venesection, showing that excessive loss of blood thereby need not be
dreaded, it being readily prevented by dividing the artery completely
across. He continued the use of ligature in the operation for aneurism,
begun by Rufus ; his method being to tie the artery above and below
the tumour ; then to incise the cyst, and procure its closure by granula-
tions. He also alludes to the operation for cataract by extraction, which
he, however, recommends very cautiously, and only when the cataract
is small. He obtained the radical cure of hydrocele by free incision of
the parts. About the commencement of the second century, Archigenes
the Syrian settled in Rome, and distinguished himself both in medicine
and surgery. His writings, which were chiefly confined to the latter
subject, are unfortunately lost. Between Celsus and Galen, however,
we meet with no great Roman writer on medicine or surgery. These
were among the last of the liberal arts that were encouraged by the Ro-
mans ; and the proud patricians refusing to educate any of their family
to such a profession, the medical practitioners of Rome were at first
importations from Greece and Alexandria, and afterwards self-educated
slaves and freedmen.*
Claudius Galenus was born at Pergamus, in Asia Minor, in the 131st
year of the Christian era. After studying at Smyrna and Corinth, he
completed his medical education at Alexandria, and ultimately settled
in Rome, where he soon obtained a great reputation both as a success-
ful practitioner and as a public lecturer on anatomy. Professional jeal-
ousy of his talents, however, drove him from Rome, to which he did
not return until recalled by Marcus Aurelius. Shortly afterwards he
was appointed physician to the young emperor Commodus, with whom,
as well as with the public, he rose to great favour. A man of great
erudition, brilliant genius, and indomitable industry, he produced
works which exerted a most powerful and extensive influence over me-
dical practice. He has the merit of rescuing medical inquiry from the
chaos in which, he found it, and restoring it to the paths of light and
nature. His fame indeed was so great as to prove, in one sense, detri-
mental to the advancement of the medical profession, inasmuch as his
opinions were received as oracular in the schools of all the civilized
* On this subject, a remarkable controversy took place in England during the ear-
lier part of last century. It was occasioned by Dr. Mead's "Orat.o Anniversary
Harveiana in Theatro R. Medicorum Londinensium Collegn hab.ta, ad diem xym.
Octobris, mdccxx.ii. Adjecta est Dissertatio de Numis quibusdam a Smyrna^ in Me-
dicorum honorem percuiss." Lond. 1724, 4to. This was followed by a pubhcation
ofDr Middleton," De Medicorum apud veteres Romanos degentium Conditione Dis-
sertatio; qua, contra viros celeberrimos acobum Sponium et Richardum Meadmm^ser
vi em a que gnobilem earn fuisse os.enditur.'' Cantab. 1726 4to. Tc> «... disser-
™ D? Ward of Greshom College published an answer in 1727 : M.ddleton pub
lished the first part of the defence in 1728, and Ward having rejo.ned in the cou
of the same year, his antagonist prepared a second part, which Dr. Heberden pn
k few copies in 176J, eleven years after the author's death.
36
HISTORICAL NOTICE.
countries for no less a period than 1300 years, thus seriously retarding
further investigation. His works were both numerous and elaborate ;
but unfortunately, he seems to have been debarred from the study of
the groundwork of his profession, human anatomy. His dissections
appear to have been limited to the simioe and other mammiferous ani-
mals, as most resembling the human structure, though on one occasion
" he felicitates himself on the opportunities he had enjoyed of examin-
ing two skeletons preserved in Alexandria, and recommends all anxious
to obtain a thorough knowledge of osteology to repair to that city." In
his early years, he practised surgery at Pergamus with marked success ;
but in Rome he seems to have confined himself almost entirely to me-
dicine, excepting the occasional performance of phlebotomy : probably
the valorous Romans had not yet lost their hatred and dread of the terri-
ble operations of surgery. Like others, however, he was still so much
of a general practitioner, as to practise pharmacy as well as medicine,
with a little of surgery: and he himself informs us, that he had a drug-
shop in the Via Sacra. " He established two general principles as the
basis of all surgery—synthesis, or the reunion of parts—diaeresis, or
their complete division, as by amputation or extirpation. In four cases
he detected luxation of the femur backwards, a variety not mentioned
by Hippocrates; and records two instances of spontaneous luxation of
the same bone. He also treats of more than one species of hernia.
But although in his writings we meet with a few bold chirurgical at-
tempts, as in the application of the trepan to the sternum in a case of
empyema, yet it must be confessed that by far the greatest part of his
surgery seems to have been confined to fomentations, ointments, and
plasters, for external affections, together with the art of bandaging, a
love for which he necessarily acquired at the Alexandrian schools ; and
the employment of complicated machinery in fracture and dislocations."
His researches were not limited to medical science, but comprehended
literature and philosophy.*
The early Christians are alleged to have unfortunately injured me-
dicine and surgery by attributing to martyrs and their relics the
power of healing wounds and curing diseases ; " acknowledging the
active interference of demons and blessed spirits in the affairs of men,
and leaving true philosophy in total abandonment."
A Cimmerian gloom was now fast overspreading the world, by
which science and art were destined to be long obscured; and shortly
after the time of Galen, we accordingly find the medical alon°- with
the other sciences encompassed by the dark clouds of ignorance and
barbarism. One or two names, however, occur worthy of notice, but
more from having preserved than advanced medical knowledge. Ori-
basius, a pupil of Zeno, lived in the time of the Emperor Julian
*Here we must refer our classical readers to a most important collection published
under the title of « Medicorum Graecorurn Opera quae exstant. Editionem curavit
D. Carol us Gottlob Kuhn, Professor Physiologiae et Pathologic in Literarum Univer-
sitate L.psiensi Publicus Ordinanus." Lipsiaj, 1821-30, 26 torn 8vo Three of
the volumes are each divided into two parts. This collection includes the works of
Hippocrates, Aretaeus, Dioscondes, and Galen. Dioscorides was edited bv Snrenjrpl
and the other writers by Kuhn. ' cpiengei,
HISTORICAL NOTICE. 37
(a. d. 350,) whose friendship he enjoyed, and became a celebrated
practitioner, as well as of great importance in the state. His works
are principally compilations, though judicious and useful. His surge-
ry is marked with timidity, discouraging operations, except in most
extreme cases, and is chiefly confined to unguents and embrocations.
He abstracted blood locally, by making deep and extensive scarifica-
tions, or rather incisions, with the knife ; a proceeding somewhat
resembling the important modern improvement in the treatment of
erysipelas, but adopted under different circumstances, and with other
objects in view.
During the fifth century the west was repeatedly invaded by the
Huns, Goths, Alans, and Lombards. Science greatly suffered in con-
sequence ; and no name worthy of remembrance is to be found, until,
about two centuries after Oribasius, appered Aetius, (a. d. 550,) a
native of Amida, and a pupil of the Alexandrian school. " His sur-
gical writings are copious and valuable. His opinions were guided
by experience, and his methods of management and cure are charac-
terized by much caution and discrimination. We find a variety of
surgical queries and suggestions which had escaped Celsus and Galen,
as Avell as the description of several diseases which have been omitted
by Paulus iEgineta. He recommended and practised scarification of
the legs in anasarca, and made free use of both the actual and poten-
tial cauteries ; he cut out hemorrhoidal tumours; operated for aneu-
rism ; tried to dissolve urinary calculi by the administration of inter-
nal remedies; and has given a series of interesting chapters on in-
flammation of the intestines followed by abscess, on encysted tumours,
on the varieties of hernia, on diseases of the testicle and castration,
on the pricks of the nerves and tendons, and, in fact, on almost every
important branch of surgical knowledge. If, mixed up with these, we
find some things which the matured experience of ages has abolished,
it is less to be marvelled at, than that surgery was already enriched
with so many valuable facts and observations. He makes no refe-
rence to the reduction of fractures and dislocations, whence it has
been plausibly inferred, " that, in all likelihood, quacks were at that
time in complete possession of this branch of practice. Better were
it for society that it was quite out of their hands now !" He seems to
have been the first to open up a field of medical inquiry, which has
since been so successfully cultivated—the nature and composition of
urinary calculi. He appears also to have turned much of his atten-
tion to the diseases of the eye, and is the first who speaks of the dracun-
culus, or Guinea-worm. Alexander of Trallis, a famous physician in
the time of Justinian, about the middle of the sixth century, was an
author of more originality than either Oribasius or Aetius. He wrote
on diseases of the eye, and on fractures ; but both treatises have been
lost, which is the more to be regretted, as, with this exception, he con-
fined himself entirely to internal disease. The celebrated Paulus
JEgineta, also of the Alexandrian school, lived about the middle of
the°seventh century, and made both large and valuable contributions
to surgery. He frequently performed the operations which he de-
scribes, and abandoned the labours of the mere theorist, for the more
38
HISTORICAL NOTICE.
valuable results of practical observation and experience. " His sixth
book has been considered by many, and not without reason, as the
best body of surgical knowledge, previous to the revival of letters."
He recommended bleeding from the immediate neighbourhood of the
part affected, in preference to general blood-letting, because more ef-
fectual ; and, for the like reason, opened the temporary artery in cases
of very severe ophthalmia. He had recourse to copious venesection,
with the view of accelerating painful descent of calculus in the ureter.
He opened internal abscesses by caustics, and defined the points at
which he thought it advisable to perform paracentesis in the different
alleged species of ascites. In lithotomy, having first endeavoured to
ascertain the situation of the calculus by the rectum, he made his in-
cision, not in the centre of the perineum, as recommended by Celsus,
but to one side of the raphe, as is now practised. Of the impropriety
of extensive incision of the bladder he seems to have been well aware,
directing that the external wound should be much freer than the inter-
nal, and that the latter should be in extent merely sufficient to admit
of the passage of the stone. While Celsus limited the operation to
patients between nine and fourteen years of age, he sanctions its per-
formance after the age of puberty, but admits that the chances of suc-
cess increase with the youth of the patient. He described more than
one variety of aneurism, pointing out those cases in which he thought
it advisable to attempt a cure by operation; and extended this to the
aneurisms of the head and joints, excepting only those of the groin,
arm-pit, and neck, instead of confining it to the tumours of the arm
alone, as had been done by Aetius. All aneurisms, excepting aneurism
by anastomosis, which he clearly and accurately distinguished, he con-
ceived to originate in rupture of the coats of the artery. He per-
formed extirpation of the mamma by crucial incision, and practised
both laryngotomy and tracheotomy. He is the first who seems to
have performed the latter operation as a means of carrying on respi-
ration during occlusion of the larynx, but naturally enough falls into
the error of transverse instead of longitudinal incison. He describes
different species of hernia, and did not hesitate to operate when the
tumour became strangulated. He is also the first who treats of frac-
ture of the patella. He was pre-eminent as an accoucheur, and was
the originator of the obstetric operation of embryotomy. From the
time of Paulus, we find no Greek or Roman surgeon of note until the
appearance of Actuarius, a Greek, who practised with great distinc-
tion at Constantinople, probably about the beginning of the twelfth
century, but at what exact period it is impossible to ascertain. Amon°-
his writings are found several surgical treatises, which, however, pos°
sess no greater merit than as compilations from previous authors *
Having thus traced surgery from its origin, through the E-yptian,
Greek, and Roman dynasties, we come to notice thf prolongftFon of
halp^bli^
Physician, translated into English : ^hhac^Vo^^\fnf1-^ ^ G™k
hens.ve viewof the knowledge possessed by the Grtlu, R™ " 'contJa'n,n«a compre-
lubjects connected with medicine ^a^^i^J^^d^b^'honM
HISTORICAL NOTICE.
89
its feeble existence in Arabia.* From Alexandria, captured by the
Saracens under Amrou in 640, knowledge was gradually communi-
cated to Arabia. Its people became acquainted with medicine through
the medium of translations of the Greek authors; and the " seat of
learning was transferred, for a time, from beneath the shadow of the
Cross to the empire of the Crescent; from the classic shores of Italy
and Greece, to the warlike followers of Mahomet, and the fiery de-
scendants of Ishmael." Many valuable manuscripts, rescued from
the savage destruction of the Alexandrian library, were carefully
transcribed or translated into the Syriac or Arabic languages, and
dispersed in various directions. The first Arabic translation was
made about the year 683, by Maserjawaihus, a native of Syria; but
the most eminent in this labour was Honain, called, by way of emi-
nence, " the translator," a Christian, born at Hira in 764. Towards
the end of the eight century, a college was founded at Bagdat by the
Caliph Almanzor ; and there medicine obtained a permanent footing,
under the fostering care of the far-famed Caliph Haroun al Raschid.
Public hospitals and laboratories were founded by him for the benefit
of students, who are said to have amounted at one time to no fewer
than six thousand, consisting chiefly of Christians banished on accouut
of their religion ; and the Caliph Almamon surpassed even his prede-
cessors in munificent patronage, extended to every department of art
and science, and in unwearied exertions to restore and propagate the
various branches of learning. By supplication he prevailed upon the
Grecian emperors to send him many works in philosophy; and, em-
ploying the best interpreters that he could find, ordered all these books
to be translated, and encouraged the industrious study of them by his
own personal example. The medical school at Jondisabour, the capi-
tal of Chorassan, established by Sapores the First as early as the end of
the third century, had by this time risen to great celebrity ; and from it
Rhazes, Hally Abbas, and Avicenna, derived their medical education.
Mesue lived during the caliphate of Haroun al Raschid, in the end of the
eighth century, and Serapion during that of Almamon, about a cen-
tury later ; both eminent medical men in their time, but both pure phy-
sicians. The first Arabian worthy in the surgical department was the
celebrated Rhazes, who presided over an hospital at Bagdat in the end
of the ninth and beginning of the tenth centuries. His works are not
remarkable for anatomical knowledge, which is not surprising, since the
study of anatomy was strictly forbidden by the Mohammedan religion,
and consequently the Arabians had to rest contented with the writings
of the Greeks on that subject. " One of their religious prejudices
against dissection was, that the soul did not instantly forsake the body,
but lingered in some particular portion of it, for some time after appa-
rent dissolution, so that the dismemberment of it might be a species of
hideous martyrdom ;" a very sufficient reason why a professor of such
* Le Clerc, Historiede la Medecine. Geneve, 1696,8vo. Amst. 1723, 4to. Freind's
History of Phvsick, from the time of Galen to the beginning of the sixteenth cen-
tury. Lond. 1725—6, 2 vols. 8vo. Le Clerc only continues the history till the age
of Galen. The literary history of the Greek physicians may be sought in the Bib-
liotheca Graca of Fabriciue.
40
HISTORICAL NOTICE.
a belief should strenuously object to the anatomization of himself and
his friends. Rhazes is the first who has described spina yentosa and
spina bifida. Of the real nature of the latter, however, he does no
seem to have had any clear idea. Regarding cancer, he advised that
the knife should never be used except when the disease was hunted,
and the whole tumour could be completely removed ; condemning the
opposite procedure as cruel and unavailing; an opinion which after-
experience has shown to be most just and true. In bites from rabid
animals, he first cauterized the wounds, and then prescribed emetics to
expel the " black bile," an evacuation considered most essential to the
cure. His account of hernia is better than any to be found in the
Greek writers. His works on surgery, however, are little more than
compilations from Hippocrates, Oribasius, Aetius, and Paulus. His
confidence in oculism does not seem to have been great; for, having
in his old age become blind from cataract, he could not, though urged,
be prevailed upon to undergo an operation for its removal. In his
time, lithotomy, and some other operations, seem to have been entirely
in the hands of juggling impostors. Hally Abbas, surnamed the Ma-
gician, on account of the extent of his knowledge and acquirements,
lived in the end of the tenth century. His great work, the Al-meleky,
written about the year 980, is, in its anatomical and physiological de-
partment, a mere transcript from the Greeks ; and his surgery possesses
but few peculiarities. " From the idea that caustics were efficacious
when a redundancy of the humours flowed to a particular part, he re-
commended their application for the cure of hydrocele. In the ma-
nagement of dropsical affections, his attention was always directed to
the remote causes ; and he preferred puncturing in the linea alba, a lit-
tle below the umbilicus, for the relief of ascites." Avicenna, who
divides with Rhazes the honour of having first introduced chemistry
into physic, flourished later than the two preceding Arabians. He was
termed, in his day, the Prince of Physicians, and seems to have been
regarded as almost miraculous for the extent and variety of his know-
ledge. He was born in 980, and died in 1036, without a rival, either
in the medical profession, or in general science. In his great medical
work, the Canon, the surgical department is not altogether forgotten, but
holds a second place to physic ; indeed, before the appearance of Albu-
casis, surgery seems to have been all but extinct amongst the Arabians.
He has distinguished between closure of the pupil and cataract, and in
operating for the latter recommends depression; extraction he considers
a very dangerous experiment. It is probable that to him we owe the
first use of the flexible catheter, as also of the instrument commonly
known as Hey's saw. His works are said to have remained the oracles
of medical knowledge for nearly six hundred years. Albucasis, who
died in 1122, exerted himself more than his predecessors in behalf of
surgery, which, by his own account, he found in a most deplorable con-
dition ; and he is chiefly distinguished as a surgical writer. Cauteries
and caustics seem to have been his favourite remedies ; and he becomes
enraptured when speaking of the " divine and secret virtues" of fire
surgically employed. The actual cautery he looked upon with venera-
tion, and describes more than fifty affections in which his experience had
HISTORICAL NOTICE.
41
found it beneficial. He is minute in his directions for its application,
and forbids its use, " except by persons acquainted with the anatomy of
the frame, and the position of the nerves, tendons, veins, and arteries ;"
from which latter circumstance some idea may be formed of the extent
to which he himself was in the habit of roasting his unfortunate pa-
tients. He checked arterial hemorrhage by his favourite method of
cauterization, but also employed styptics, as well as complete division
of the vessel and ligature. He is supposed to have been the first to
remark, that it is by the formation of a coagulum in the orifice of an
artery that its calibre is closed and hemorrhage arrested. He has de-
scribed a particular instrument of his own for the cure of fistula lachry-
malis, and the needle used by the surgeons of Irak for cataract. He
speaks of operating for the relief of hydrocephalus, but the success of
the practice does not seem to have been greater then than in its revival
in our own time ; for he confesses that he knew of but one successful
case, and therefore does not recommend the operation. He seems to
have been conversant with the mode of removing tumours by ligature
when the knife is inexpedient; he advises amputation in gangrene of
the extremities ; and is the first who has described the mode of ex-
tracting calculus by incision in the female. His method of lithotomy
resembled that practised by Paulus iEgineta; and like him, he seems to
have been bold in puncturing and excising the tonsils, removing the
uvula when obstinately relaxed, and extracting polypous tumours from
the fauces. He mentions bronchocele as occurring most frequently
among women ; but, fond of the knife and cautery as he Avas, he does
not seem to have employed either for the removal of that tumour ; in-
deed, he tells us of " an ignorant operator, who," in attempting extir-
pation of a bronchocele, " by wounding the arteries of the neck, killed
the patient upon the spot." He invented the probang, for dislodging
foreign bodies from the gullet; and in wounds of the intestines, prac-
tised union of the divided parts by suture more than once with success.
Though thus bold in his operations, and, like all the Arabians, too fond
of the employment of instruments, he was not however, without judg-
ment and caution. For example, he condemns tracheotomy as worse
than useless when the inflammatory action of the windpipe is acute,
and has extended to the bronchi; an opinion which is acknowledged
as true, though unfortunately not always followed in the present day.
And he exceeds even Rhazes in his dislike to operative interference
with cancerous tumours, declaring that he never either cured, or saw
cured, a single instance of that disease ; a conclusion too nearly con-
sistent with the history of that most implacable malady in all succeed-
ing ages. His remarks on abscesses are most judicious ; directing par-
ticular attention to their situation, and recommending their being early-
opened, whether " matured" or not, when in the neighbourhood of
joints or other important parts, which would be injured by their conti-
nuance ; a rule of practice which, if more faithfully followed, would
materially diminish the number of diseased joints and bones. He also
advised what has since been so much insisted on by Mr. Abernethy,
that when the abscess is very large, its contents should be evacuated
by degrees. He is the only one among the ancient writers on surgery
42
HISTORICAL NOTICE.
who has described the instruments used in each particular operation.
Avenzoar, a Spanish Arab, practised physic with distinction, about the
bcnnnino- of the twelfth century, at Seville in Andalusia. He "escribes
inflammation and abscess of the mediastinum, from which he had him-
self suffered ; and mentions a case of abscess of the kidney, from which
fourteen pints of matter were evacuated. He speaks of bronchotomy
as expedient in dangerous cases of inflammation of the tonsils: and in
stricture of the gullet proposes three modes of treatment; the occasional
passage of a tin or silver tube ; the use of a milk bath, that nutritious
particles may be taken up by the pores of the skin ; and the injection
of nutritious fluids by the rectum. He also details cases of " rupture,
fracture of the hip-bone, wounds of the arteries and veins, tumours,
and other varieties of surgical disease, which he appears to have un-
derstood well, and treated with discretion." He does not complain,
like Rhazes, that lithotomy was in the hands of mountebanks, but tells
us that the Arabians then reckoned such operations " filthy and abomi-
nable, and unfit for any man of character to perform ;" and held that
" no religious man, according to the law, ought so much as to view
the genitals." The brightest name in the history of Arabian philoso-
phy is that of Averrhoes, the pupil of Avenzoar, born at Cordova about
the middle of the twelfth century, and said to have died in the year
1206. But he cultivated the study of medicine only as a branch of
general philosophy, and surgery he seems to have altogether neglected.
Such were the Arabians. Of these, Albucasis was the most famous
in surgery, as Celsus had been among the Romans, and Paulus JEgineta
among the Greeks. But even he could not escape the unfortunate fail-
ing of the Saracenic school; endless invention of manifold and compli-
cated instruments, attaching far too much importance to the mechanical
part of their profession, and mistaking the inspiration of terror and
infliction of cruelty for energetic and judicious surgery. In order, for
example, to arrest hemorrhage from a wounded surface, if time pressed
and assistants were scarce, it was not uncommon to dip the part into
boiling pitch, a liquid which was then dignified with the appellation of
a styptic. They, however, systematically divided physic, surgery, and
pharmacy into three distinct professions : and so, by commencing the
division of labour, may be considered as having done something not
unimportant towards the ultimate advancement of medical knowledge.
" The last traces of their intellectual illumination appeared amono- the
Spanish Moors in the thirteenth century, when the Christian arms having
become more and more powerful, they were compelled to substitute the
field for the study—the sword for the pen—and, before an overwhelm-
ing opposition, were at length driven from a region whose fields they
had tilled, and whose olives they had gathered, for a thousand years.
With the decline of the Saracenic school, the daylight of science went
down over the nations; and an intellectual darkness, which endured
for three hundred years, enveloped the general face of society. All the
fountains of science were dried up, and the world seemed retroo-rading
into the unillumined chaos of ignorance."* °
* Moir's Outlines of the Ancient History of Medicine. Edinb. 1831 16to Of
this excellent work we have not scrupled to make free use in the course of thp nr»
ced n;: observations. rre-
HISTORICAL NOTICE.
43
A knowledge of the Greek and Arabian systems of medicine was
introduced into Italy, at Salerno, in the beginning of the eleventh cen-
tury ; and this school soon rose to celebrity as a seat of medical learn-
ing. In the time of the Crusades, Salerno was a place of great resort
for warriors of all nations passing between Europe and Palestine ; and
by these wanderers, on their return, the light of medical science was
thence slowly conveyed over Europe. It obtained the privileges of a
university; but the medical school of Salerno did not long retain its
high reputation. In modern times, it is chiefly remembered on account
of the Regimen Sanitatis Salernitanum, a singular production, of which
more than one hundred and sixty editions are known to have been pub-
lished. Though written in the name of the Schola Salernitana, it has
generally been ascribed to Joannes de Milano. The English king to
whom it is addressed is supposed to have been Robert of Normandy,
whose claims to the English crown were recognized by some of his
contemporaries. The poem opens with these lines :
Anglorum Regi scripsit Schola tota Salerni,
Si vis incolumen, si vis tereddere sanum,
Curas tolle graves, irasci crede profanum,
Parce mero, coenato parum, non sit tibi vanum
Surgere post epulas, somnum fuge meridianum,
Non mictum retine, nee comprime fortiter anum.*
In the twelfth century, the Jews practised medicine, not only among
their own tribes, but also among the Moors and Christians ; and though,
like all others of this age, merely treading in the beaten track of the
Greeks and Arabians, yet, from their superiority in such learning, they
came to be reputed the most skillful practitioners. About the middle
of that century, as has already been stated, surgery was completely
separated from physic, by the edict of the Council of Tours prohibiting
the clergy,! who then shared with the Jews the practice of the healing
art in Christian Europe, from in any way causing the effusion of blood,
at least as a means of curing bodily ailment. Surgery was in conse-
quence abandoned to the uneducated laity, and sunk to a deplorable
state of prostration ; it became a mere matter of plasters and unguents;
and if any thing happened to be written on the subject, it was but a
bad compilation from the Arabians.^: We shall, however, notice some
* Regimen Sanitatis Salernitanvm ; a Poem on the Preservation of Health, in rhym-
ing Latin verse, addressed by the School of Salerno to Robert of Normandy, son of
William the Conqueror, with an ancient translation ; and an introduction and notes
by Sir Alexander Croke, D. C. L. and P. A. S. Oxford, 1830, 12mo.
t The early clergy claimed the practice of medicine as their peculiar privilege, and,
using it chiefly as a means of personal power and gain, disgraced it by ignorance, char-
latanry, and imposture. It was to check this that the Roman Council assembled by
Pope Innocent II in 1139, threatened with the severest penalties those monks and can-
ons who applied to the practice of medicine, " neglecting the sacred objects of their
own profession, and holding out the delusive hope of health in exchange for ungodly
lucre." But even this, though followed by the more peremptory edict at Tours in IHJ3,
where Alexander III. presided, did not make them altogether forego what they found
so convenient and profitable. It was necessary to repeat the edict in 1179 and 1216 ;
but notwithstanding, the monks continued still to practice physic, and it was chiefly
by theirevil influence that the school of Salerno was brought to decay.
t The writers of that age were aptly termed by Severinus, Arabistae.
44
HISTORICAL NOTICE.
of the more remarkable events in connexion with it during its tempo-
rary abasement. In the year 1271, the foundation of the College of
Surgeons at Paris was laid by Pitard, a surgeon of eminence in those
days, and whose enthusiasm effected something towards raising his
humbled profession. About the same time lived (iulielmus de Saliceto,
a professor at Verona, said to have been " a powerful man" in both
surgery and medicine. He seems to have earnestly dissuaded men
from the copying and study of books in preference to practical expe-
rience, and he himself set a better example. In our own country,
Gilbcrtus Anglicanus is the first name connected with surgery ; but he
seems to have been little more than a compiler from the Arabians. He
lived about the beginning of the fourteenth century ; and shortly after
him appeared John of Gaddesden, author of the Rosa Anglica, and said
to have been an erudite and ingenious man, as well as a skilful practi-
tioner. About the middle of the fourteenth century, Guy de Chauliac
practised with renown at Avignon, and is " accounted one of the re-
vivers of the languishing art." The amputating knife was held in but
slight esteem by him, as will afterwards be shown. In his Chirurgia,
a history of the state of surgery in his day,* we find the first mention of
the Caesarean operation. Contemporary with him was John of Ardern,
an English surgeon. He wrote with simplicity and honesty, and may
be regarded as a reviver of surgery in that country. In his practice he
was peculiarly successful in the treatment of fistula in ano, and thereby
acquired a great reputation. He also improved both the use and the
construction of the trepan ; adding the central pin, and limiting the
operation to the severe forms of injury of the head. Valesco de Ta-
ranta, a Portuguese, practised at Montpelier, and wrote on surgery in
the beginning of the fifteenth century. He was the first who proposed
the cure of cancer by the application of arsenic. About the "middle of
the same century, lithotomy, the practice of which had hitherto been
confined to itinerant and ill-informed operators, was restored to the
regular profession by Germain Colot, a French surgeon, high in favour
with Louis the Eleventh. He first contrived to witness the ope-
ration by the itinerants, then practised it on the dead body, and at last
performed it successfully on a condemned criminal who happened to
be afflicted with stone, and who consented to undergo the operation on
condition of being pardoned if he survived. His success, in having
thus doubly saved life, obtained for Colot much renown ; and lithotomy
ever after continued a regular part of surgical practice.! The fifteenth
century contains two other events important to surgery; the discovery
of the art of printing, about the year 1450, which gave a new impulse
* Some idea may be formed of the languishing state of surgery at this time, from his
division of the surgeon into the following five sects. The first applied cataplasms in-
discriminately to every description of ulcer and wound. The second in similar r-.^ea
employed wine only. The third used emollient ointmentsand plasters The fourth
chieflv militarv sursreons. nromisciinnvlv cmnlmra/i n:i„ ____i ___• . 'uu,u,>
t In the beginning of the sixteenth century, cutting upon the staff Was introduced bv
Johannes de Rormmis and Mar.anus Sanctus, and very successfully followed bv I ,7
rence Colot, a descendant of Germain. J lu,luwea °y A-au-
HISTORICAL NOTICE.
45
to science and literature, by rendering the accumulated stores of know-
ledge more accessible ; and the alleged importation of the venereal dis-
ease from America, by the first discoverers of that continent, giving the
small pox as if in exchange, about the year 1493.* In this century
also the Turks captured Constantinople, thus overthrowing the last
remains of the eastern empire ; and by the multitude of Christians who
fled from that city many manuscripts of the Greek medical writers were
brought to Italy, and their contents thence slowly disseminated over
Europe.
Hitherto surgery can scarcely lay claim to an actual revival. Occa-
sional attempts had been made to raise it from its low position, but all
proved abortive. At length, however, in the beginning of the sixteenth
century, the practitioners of the healing art were happily convinced that
the observation of nature was superior to compilation from the ancients,
whether Arabian, Roman, or Greek ; they consequently ceased to tread
blindly and servilely in the footsteps of their predecessors, and a new
era arose to the profession. About the same time Vesalius gave birth
to anatomy, properly so called ;f illuminated by which science, surgery
became a worthy object of pursuit to men of talents and education, and
under their cultivation it was gradually raised to an enlightened and
liberal profession.
The most conspicuous name in this new era of surgery is that of Am-
brose Pare, a Frenchman. In this country surgery was then sadly
depressed, having retrograded since the time of John of Arden. Its
list of practitioners comprised barbers, farriers, sow-gelders, cobblers,
and tinkers ; and it is not matter of surprise that from among these no
name has been handed down as worthy of remembrance. The com-
bination of the practice of surgery with the more harmless manipulations
of the barber, was not confined, however, to this island, but existed
also in France, and continued in both countries for upwards of two
hundred years. The great Pare does not reject the appellation of bar-
ber-surgeon, as applied to himself; nor does he seem to think that there
is any thing derogatory in the title. He was surgeon successively to
* The first author who clearly describes the venereal disease is Marrellus Cuma-
nus, who wrote in 1495. It was not till 1530 that Fracastorius wrote his celebrated
poem De Morbo Gallico, in reference to which it has been said that the chaste and
classic elegance of its language was worthy of the best days of imperial Rome, and
the mellifluence of its versification hardly surpassed by the bard of Mantua himself.
By G. Torella, physician to Pope Alexander the Sixth, we are informed that the in-
sane abuse of mercury as a means of cure was not quite a universal practice on the
outbreak of the disease ; for, in describing some particular forms of mercurial oint-
ment, he himself states that " they destroyed an infinite number of people, who in this
case did not die, but were downright killed ; and these bold empirics must give an ac-
count, if not in this, in the next world, of their practice, and be drowned in the pit of
repentance." It is but very lately that the " pit of repentance" ceased to be useful
under very similar circumstances. That the venereal disease existed, however, in
Europe, centuries before the return of Columbus from Spain, seems sufficiently estab-
lishes by reference to the earlier authors ; Albncasis and Avicenna mention ulcers
and warts upon the penis; Gulielmus de Saliceto. 1280, treat of buboes caused by
disease of the penis from impure intercourse ; and both Valesco and John of Gad-
desden (1305-1320) mention pustules and ulcers of the penis from a similar cause.
tA little later in the century, Fallopius taught anatomy at Pisa, and Eu.sUichius at
Rome, aud to their efforts, as well as to those Vesalius, the advancement of that sci-
ence is much indebted. Fallopius died in 1563; Eustachius in 1574.
46
HISTORICAL NOTICE.
Henry the Second, Francis the Second, Charles the Ninth, and Henry
the Third, of France ; and followed the French armies in all their cam-
paigns down to the battle of Moncontour in 15G9. His consequent
experience of gun-shot and other Avounds, on the field of battle, natu-
rally directed his attention to the subject of hemorrhage ; and it is to
him that we owe the revival and improvement of the method of arrest-
ing bleeding from arteries by ligature, and discontinuance of the caute-
ries and styptics, which, to the disgrace of surgery, had hitherto been
in exclusive use for this purpose. Yet so averse are mankind to aban-
don their ancient customs, that the improvement of Pare was not sanc-
tioned till after much abuse and persecution, directed both against him-
self and his discovery; indeed, so bitter and unrelenting were hia
jealous brethren that he was compelled, for his own safety, to adduce
garbled and incorrect extracts from Galen and other ancients, in proof
that to them, and not to him, the invention was to be referred. So far
he was less in error than he himself supposed, for we have already
stated that he has merely the merit of reviving the use of the ligature.*
Celsus distinctly advises its employment when pressure fails to stop
arterial hemorrhage; and Albucasis sometimes condescended to use it
instead of his favourite cautery and cruel styptics. But so little had
surgeons in general profited in this respect, before the time of Pare, that
amputations usually proved fatal, partly on account of the hemorrhage,
partly in consequence of the severe measures employed for its arrest.
We find Guy de Chauliac asserting that it Avas better " to let the limb
drop off than cut it off;" and his own operations consisted in placing
pitch plasters very tightly round the joint, and thus causing the limb to
mortify. Pare was amply repaid by future fame for the opposition
which he had at first sustained. He rose to an unparalleled height of
popularity with the army, by whom he was absolutely adored. On one
occasion, his mere presence among the garrison of a beleaguered city
about to capitulate, re-animated the troops to such an extent, that their
resistance became more energetic than before, and the besieging army
perished beneath the walls. By his sovereigns he was also highly
esteemed. From the general massacre on the fearful night of St. Bar-
tholomew he was rescued by the personal exertions of Charles the
Ninth, his great merits being appreciated even by that weak and cruel
monarch. But he was not content with the respect and praise of his
contemporaries ; his writings, the result of great experience and accu-
rate observation, freed from the yoke of authority, and digested by
genius of a high order, have rendered him immortal. He was the first
to use the twisted suture in hare-lip, and similar wounds, copying the
mode of application from the manner in which the ladies and tailors of
the day wound the thread round the needle, and thus carried both safely
in their cuffs or caps. His works, first published in 1535, and after-
wards more fully in 1582, exerted a most powerful and beneficial influ-
ence upon his profession. The influence was not, however, immedi-
*As an example of how little the hint of Celsus was attended to, we may mention
that Procopius relates how Artabazes perished of a wound in the neck, " the arterv
of the neck having been cut through, so that the blood could not be stopped " "Their
cauteries and styptics had no effect on the carotid, or its larger trunks
HISTORICAL NOTICE.
47
ate: for at his death the light he had shed was for a time obscured,
surgery reverting to the state of degradation in which he found it, in
consequence of its baneful association with barberism. Pigrai was his
successor, but an unworthy one : endeavouring to follow the footsteps of
his master, he obscured and almost effaced them. The most interesting
of Pare's surgical treatises is that on gun-shot wounds, a class of injuries
then of recent introduction, and little understood : the murderous cannon
and firelock had not been long in use.
In the seventeenth century, surgery again revived, resuming the im-
pulse which the genius of Pare had imparted. Italy produced Caesar
Magatus, who simplified, and consequently must have improved, the
treatment of wounds; the never-to-be-forgotten Tagliacotius, with his
rude repairs of the human face; and Marcus Aurelius Severinus, a
skilful and intrepid operator. At the end of the sixteenth and begin-
ning of the seventeenth centuries, Padua was favoured with Fabricius
ab Aquapendente, the preceptor of Harvey, a most distinguished physi-
ologist, and the most eminent surgeon of his time. His Opera Chirur-
gica passed through no less than seventeen editions, and contain not
only an excellent digest of surgery as it then was, but also many im-
provements of his own. To him we are indebted for the modern Tre-
phine, and for the use of the tube after tracheotomy. About the middle
of the seventeenth century arose the true father of British surgery,
our own Wiseman, the Pare of England. One or two English names
are to be found before him: William Clowes, a military surgeon of
some eminence, attended the Earl of Leicester's army in the Low
Countries, and wrote on gun-shot wounds ; and Lowe, a Scotchman,
gave to the world a Discourse on the whole Art of Chirurgery, dated
1612 : but Wiseman, doubtless, is the first Briton worthy of note in sur-
gery. He was serjeant-surgeon to Charles II., and, amidst the horrors
of the civil wars had ample scope for the study of his profession. His
surgical works, consisting of eight treatises, dated 1676, contain much
information, at that time most valuable, and still amply rewarding an
attentive perusal. In military practice he strongly advocated immediate
amputation, " while the patient is free of fever," in the case of such
injuries as rendered preservation of the member improbable, of course
allowing the primary shock of the accident to be past; a point of practice
which long discussion in after years served to confirm. It was not till
his time that surgeons ceased to believe that gun-shot wounds were
necessarily envenomed by the powder and ball, and had to be treated
accordingly with potent and cruel dressings. The immortal Harvey,
contemporary with Wiseman, cannot, perhaps, be classed among the
eminent surgeons, having principally confined himself to anatomy and
physiology, yet he is inseparably connected with that science by his
discovery of the circulation of the blood ; a discovery which has done
so much for the advancement of all medical knowledge, but of surgery
in particular. James Young, a surgeon in Plymouth, may be said to
have been also contemporary with Wiseman, having written in 1679.
He is the first who proposed amputation by a flap, an improvement to
which two French surgeons, Yerduin and Sabaurin, lay claim ; and he
48
HISTORICAL NOTICE.
is also the first who recommends limited compression of the main artery
in amputation. . .
Germany boasts of several eminent surgeons of this time ; labncms
Ilildanus, a most successful practitioner, and author of a surgical trea-
tise, dated 1641; Scultetus, author of the work, celebrated for its horrid
array of lethal weapons, called Armamentarium Cliirnrgicuin, 1653 ;
and Purmann, who displayed too great an attachment to the dangerous
representations of Scultetus. Heister, a professor in the university of
Helmstadt, wrote a system of surgery, which has been translated into
most of the European languages, and is still in high repute.
Holland likewise possessed successful practitioners of surgery, but
tainted Avith an umvorthy concealment of their methods of cure. Ran,
a native of Germany, though a professor at Leyden, Avas perhaps the most
successful"lithotomist that ever lived. He kept his method of operating,
Avhich he had been taught by Frere Jacques, a profound secret, and made
it a mystery even to his OAvn pupils, as appears from the circumstance,
that his two favourites, Heister and Albinus, of a more liberal spirit
than their master, in attempting to divulge his secret for the benefit of
the profession at large, have varied most materially in their statements.
This illiberal spirit pervaded the other branches of medicine as Avell as
the surgical. The famous anatomist Buysch preserved inviolate the
secret of his Avonderfully minute injections, although really the discovery
of his friend De Graaf; and Roonhuysen, the accoucheur, worked
stealthily with his invented lever. The latter was probably the first
who had recourse to tenotomy, for the removal of deformity, having
divided the sterno-mastoid for wry-neck. The succeeding generation,
however, removed the stigma of secrecy from the Dutch ; and their
great Camper Avas equally celebrated for the number of his discoveries
and the zeal with Avhich he made them known.
From the time of Pare, France produced no surgeons of great emi-
nence until the eighteenth century. In the seventeenth, Ave find the
names of Dionis, Belloste, Saviard, Morel, and a few others of some
renoAvn, but not at all equal to their contemporaries in other nations.
Some idea may be formed of the then feeble condition of surgery in
France, from the fact that Louis XIY- was not cured of a simple fistula
in ano until after his life had been in no small degree endangered by
repeated abortive operations. That the French can boast of ^surgeons
of the first class in the next century, however, is indisputably shown by
the simple mention of Petit and Desault; names that must ever occupy
a proud place in the annals of surgery. The former, adding to the
most powerful talents great industry, and an innate love of his pursuits,
rose rapidly to eminence, though not without much envious opposition,
which seems to be the portion of nearly all those who occupy a pre-
eminent place in the profession. On general surgery he has left a work
of much value ; and his treatise on diseases of the bones, though pro-
duced at an early age, entitles him to be called the father of that branch
of pathology. For many years it remained the best work on the sub-
ject. He Avas the inventor of the screw-tourniquet, and the first who
operated for fistula lachrymahs by transfixion of the sac. He contributed
largely to the Memoirs of the Royal Academy of ^r^rj^^^
HISTORICAL NOTICE.
49
which has done much for the advancement oi surgery, not only in
France, but throughout the Avorld. Its Memoirs, containing the result
of the labours of many eminent men, constitute a work of the greatest
value. Desault, also of high reputation, both as an anatomist and a
surgeon, Avas the first who taught surgical anatomy, and gave clinical
lectures on surgery. His improvements on the apparatus for fractures
were most important; and a splint invented by him is still in use,
modified, for fractures high in the femur. His adaptations of cutting
instruments were also good ; among others, changing the amputating
instrument to a straight knife, instead of the old curved weapon. He
was the first Avho contemplated the cure of artificial anus, resulting from
strangulated hernia ; and he further improved Pare's revival of ligature
of the arteries. The proposal of curing aneurism by ligature of the
vessel on the distal side of the tumour, originated Avith him: a pro-
ceeding, however, of Avhich the merit is still dubious. His Avritings
are both valuable and extensive. After the great names of Petit and
Desault, not a few French surgeons of the same century, though less
eminent, yet deserve mention; Le Dran, a copious and excellent
author; Sabatier, famous in the department of operative surgery ;
Garengeot, Louis, La Motte, Frere St. Cosme,* Portal, Pouteau, Lecat,
Chopart, Morand, Moreau, &c.
It is about the middle of the eighteenth century that our attention is
first attracted to our Transatlantic brethren. In 1763, lectures on ana-
tomy and surgery were delivered in Philadelphia by Dr. Shippen ; and
in 1791 the medical school of that city was completely established,
under Benjamin Rush, the Hippocrates of Colombia; a school Avhich
has since lent valuable aid to the progress of both medicine and
surgery.
Our OAvn country was at this time by no means barren in surgery.
Percival Pott and John Hunter are names which occur, the one in the
middle, the other in the end, of the eighteenth century, and are fully
equivalent to Petit and Desault; indeed Hunter may be justly ranked
as the greatest man that ever graced the profession. Pott, the best
author, operator, and practical surgeon of his time, greatly improved
the practice of surgery in England, both by his Avritings and by per-
sonal example. Like Desault, his attention Avas particularly directed
to the treatment of fractures, of which he had some painful experience
in his own person, having sustained a severe compound fracture of the
leg. He has left a justly celebrated treatise on the subject. On am-
putation his observations are most important, clearly discriminating
* Frere Jean de St. Cosme, although a monk, was the inventor of the Lilhotome
Cache, and with it obtained wonderful success and celebrity as a lilhotornist. He
considered himself specially commissioned by Heaven to cut for stone, fistula, and
rupture; and led a life of the greatest practical piety and self-denial, seeking only
enough of money to obtain the ordinary necessaries of life, and to keep his instruments
efficient. Though at first an uneducated friar, he certainly had the merit of having
converted the tearing into a cutting operation with success. In 1700 he studied an-
atomy at Versailles under Du Verney, and then improved his operative procedure
by laying the foundation of the lateral operation, as now practised, with the knife.
He received a medal from the Senate of Amsterdam, bearing the motto, " ob cives
servatos," a,nd was presented with golden sounds at the Hague. He taught his op-
eration to Rau and Marechal; the former of whom practised it with remarkable
success, but with an unworthy secrecy.
5
50
HISTORICAL NOTICE.
between those cases, of injury more particularly, which demand the
operation, and those which do not; at the same time marking the period
most advantageous to its performance. Regarding injuries of the head,
he Avrote with more precision, and at the same time with more origi-
nality, than any previous author, and will ever remain a valued autho-
rity upon that subject. The same may be said of his description of
vertebral disease, he having been the first who clearly distinguished
between those curvatures of the spine depending on mere change of
form in the bones, and those occasioned by caries or abscess ; the latter
formidable affection is still known as " Pott's Disease" of the vertebras.
He greatly improved the treatment of fistula in ano, and abscesses in
general; and by simplifying the Avhole art of surgery, discarding the
cautery and escharotic unguents, or rather limiting them to their proper
place and use, employing also the cutting instruments Avith caution and
reserve, and placing more implicit trust in, and showing more respect
for, the poAvers of nature than had hitherto been the custom, he achieved
a most important and beneficial reform. Until his time, the maxim
" Dolor medicina doloris" remained unrefuted. The actual cautery,
for example, Avas in such general use, that " at the time Avhen surgeons
visited the hospital, it was regularly heated and prepared in the wards,
and in the presence of the patients, as a part of the necessary apparatus.
Mr. Pott lived to see these remains of barbarism set aside, and a more
humane and rational plan, of Avhich he was the originator, universally
adopted." John Hunter, a native of Scotland, the pupil, first of Che-
selden, and afterwards of Pott, though not remarkably distinguished as
an operator, Avas the most gifted surgeon of Avhich the medical profes-
sion can boast, and no less eniment as an anatomist, physiologist, and
general philosopher. His researches comprehended a Avider range than
those of Pott, but arrived at the samefcend, the improvement of surgery.
The knovtledge obtained by his vast inquiries into physiology, patho-
logy, and human and comparative anatomy, was, with all the power
of his genius, brought to bear upon the practice of the profession, and
with the happiest success. The doctrines of adhesion, granulation,
and inflammation with its various results, Avere, until explained by him,
comparatively obscure and uncertain ; and no one is ignorant how
much the successful treatment of disease, either by surgery or medi-
cine, must ever depend on an accurate and familiar knoAvledge of these
rudiments. To him Ave are indebted for the simplification of more than
one operation, the discovery of the vitality of the blood, important ad-
vice as to the treatment of gun-shot Avounds, the enforcement of excision
of bitten or poisoned parts, many neAv facts as to the physiology and
pathology of teeth, and other valuable additions to practical surgery.
But these assume an unimportant place among his deeds, when placed
beside the two Avith Avhich his name is indelibly associated—the cure
of popliteal aneurism by ligature of the femoral artery, and the elucida-
tion of the venereal disease ; his Avork on the latter subject still remain-
ing standard, and in many respects unsurpassed. His improvement of
the operation for aneurism marks an era in the history of surgery, being
one of the most important of its advances. Dissatisfied with the'cruel
formidable, and unsatisfactory operation for popliteal aneurism, byinci-
HISTORICAL NOTICE. 51
Bion of the tumour and ligature of the vessel at its diseased part, as
first practised by Rufus and Antyllus, he made himself aware of the
causes of failure by the old system, contemplated the plan of cure
which bears his name, satisfied himself of its practibility by diligent
study and experiment, successfully brought it to the test of actual prac-
tice ; and then, extending the principle to all aneurisms, effected for
surgery a great triumph over that formidable disease.* His first opera-
tion was performed in 1785. Since his time the method of applying
the ligature has been considerably improved, and the certainty of suc-
cess consequently increased. But " the "more brilliant a discovery,
and the more beneficial its results, the more certain is its author of be-
coming the butt of envy and the object of detraction. And accord-
ingly Ave find that Hunter has not been permitted to remain in undis-
turbed possession of his discovery. Its merit has by some been claimed
as due to Aetius ; others, with better hope of success, support the pre-
tensions of Guillemeau (a pupil of Ambrose Pare,) Anel,f and Desault;
but a candid inquiry into facts and dates will ever result in ascribing
the honour to our illustrious countryman. Had he evenibeen deprived
of this, his name must still have been immortalized by other and more
palpable labour of his mind and hand—his Avritings and museum.
In the same century with Pott and Hunter, Britain also produced
White, an excellent practical surgeon and lucid writer, the originator
of Excision of joints ; Cheselden and Douglas, two eminent lithoto-
mists, the former peculiarly successful; Sharp, famed for his Critical
Inquiry into the State of Surgery; and Monro, a name indissolubly
united with the birth and fame of the Edinburgh medical school.£
In Italy, Avhere, during the times of Pott and Hunter, several emi-
nent surgeons lived, Lancisi, Morgagni, Bertrandi, Troja, &c.—the
labours of Hunter in aneurism Avere ably followed up by Scarpa, who
still farther elucidated the doctrines regarding the new treatment of
that disease, and established the success of the operation. He Avas
also eminently successful in his researches as to the anatomy and patho-
logy of hernia, a subject Avhich he has made peculiarly his own. The
same century saw in Germany, Schmucker, Richter, and the great
Haller, Avhose Disputationes Cliinirgic.oz bear, equally Avith his other
works, the impress of both labour and genius of a high order.
The nineteenth century will not yield to any former era in a nume-
rous and bright array of names dear to surgery. It has seen the fall of
Abernethy, Dupuytren, and Cooper, brilliant stars in the galaxy, and
mourns others highly valued; but vast and powerful is the host who
* " So discouraging were the results of the old operation, that many surgeons
preferred performing amputation of the aneurismal limb."
t Guillemeau and Anel placed their incisions and ligatures in the immediate
neighbourhood of the tumour.
% Dr. Monro was appointed professor of anatomy to the company of surgeons in
1719, and during the ensuing year he wasappointed to a similar chair in the univer-
sity. Several other professors in the same faculty had previously been nominated ;
Sir Robert Sibbald, Dr. Halket, and Dr. Pitcairne, so early as the year 1683. But
Dr. Monro was the first who regularly delivered public courses of lectures, and he
may in a great measure be regarded as the founder of the medical school of Edin-
burgh.
52
HISTORICAL NOTICE.
are still labouring with distinguished success, in their noble calling
In all civilized countries, the dark days of the profession have, we
trust, for ever passed away ; and many are the lUustnous names in
which it now exults, more particularly in I ranee, Germany, and, last
not least, Great Britain.
Occasional reference to the following diagram of the blood's con-
stitution may be found useful, particularly as the first subject treated of
is so intimately connected with important changes m that fluid.
DIAGRAM OF BLOOD.
Chemical Components.
o
Liquor
Sanguinis.
Water.
Various salts.
Fatty matters.
■{ Extractive do.
Albumen.
i Serum.
Fibrin.
Red Corpuscles.
Crassa-
mentum.
o
>
d
>
o
o
O
—Wharton Jones, Brit. and. For. Med. Rev., xxviii. p. 588.
THE
PRINCIPLES OP SURGERY.
SECTION I.
CHAPTER I.
PERVERTED ACTION OF THE BLOOD-VESSELS.
OF INFLAMMATION AND PERVERTED VASCULAR ACTION IN GENERAL.
Inflammation, the source of much evil, medical as well as surgical, -
may be defined: A perverted condition of the blood and blood-vessels of
a part interrupting its healthful function, and changing its normal struc-
ture ; ordinarily attended Avith redness, pain, heat, and swelling; and
inducing more or less disturbance of the general system.
This term has, in my opinion, been made to include too wide a
range of action—from the slightest exaltation of Avhat is healthy, to the
most disastrous results of ravaging disease; rendering the cause of
simple effusion one and the same with that of suppuration, ulceration,
and gangrene ; uniting, as if in one harmonious operation, the healing
of a Avound with its gaping and suppuration—the gradual enlargement
of a part, with its destruction and discharge—the death of a portion of
bone, Avith the formation of its substitute—the successful reunion of a
broken limb, Avith the suppurative arrest and undoing of the callus—
the infliction of an ulcer, Avith its process of healing:—all, however
dissimilar, declared the offspring of one common parent—Inflam-
mation.
The practical confusion and tendency to error Avhich inevitably result
from such a state of things, seem full warrant to the surgeon at least,
for an endeavour to divide Avhat is so extensive and varied, into its
component parts ; and, considering each disjunctively, to inquire whe-
ther separate causes may not thus be found to suit the results so widely
different.
With this view, I would, in the first place, limit the term Inflamma-
tion to Avhat is essentially morbid; that is, at variance with healthy func-
tion and structure. The blush of shame, or the red spot of hectic, are
5*
54
PRINCIPLES OF SURGERY.
not the same with the fiery tumour of erysipelas ; the increased vascular
action of the mamma giving milk, is different from that thoroughly per-
verted vascular action which arrests the secretion, and changes the
structure of the organ ; the simple turgescence winch at once closes a
flesh wound, is an action far short of that Avhich renders its lips separate
and swoln,'pouring out a copious purulent discharge. The one is
something not at variance with health : the other is Inflammation^
From health to true Inflammation is not one step, at once attained,
but a transition gradually effected—the time occupied varying according
to circumstances. In some cases a very feAV hours suffice ; in others,
days shall have elapsed, and yet the process is incomplete.
The transition may be conveniently subdivided into three stages :—
1. Simple Vascular Excitement; 2. Active Congestion; 3. True In-
flammation. We cannot yet state Avith certainty the exact details of
the process; but believe- them to be nearly as folloAvs :—
Theory of the Inflammatory Process.
Let us take a common surgical example—the application of some
acrid substance to the skin. Each component texture of this pari may
be affected, so soon as brought in contact with the irritant, yet it is not
improbable that one texture may be involved sooner and more seriously
than the others. This one is the nervous ; and hence immediate pain, by
the effect on its sensory portion. An impression is thus conveyed from
the part to the nervous centre ; thence folloAvs, by reflex action, a sti-
mulus to the vascular tissue of the part, already roused by the direct
influence of the irritant, and that stimulus is in due time obeyed ; as if
both part and system resented the injury, and had resolved to resist or
repair the evil by a functional effort, the greater share in which falls to
be borne by the blood-vessels.*
The time Avhich elapses between the application of the exciting cause
and the establishment of vascular action thereby induced, is termed
the period of incubation ; varying as to duration—in some cases very
brief, in others protracted—ahvays valuable With regard to treatment.
I.—The action commences with determination of blood to the part;
an unusual amount of that fluid reaches it, and is sent through it Avith
an augmented velocity. At first the capillaries and minute arteries—
those vessels mainly concerned in the change—are of diminished cali-
bre ; a change resulting from an inherent contraction of their walls, or,
secondarily, from contraction of the parenchyma, or,—as is most proba-
* Mr. Wharton Jones ingeniously supposes that the initiatory effect on the nerves of
the part is double; first, on the sensory nerves; secondarily, on those of motion__
producing excitement of the former, depression of the latter. That the exciting
cause acts " primarily on the sensitive nerves, exalting their activity. The motor
nerves of the vessels which have sj mpathetical relations with the excited sensitive
nerves, are secondarily affected. But this affection of the motor nerves oftheves
sels, which supervenes by reflex action on the excitement of the sensitive nerve is not
a corresponding state of excitement, but an opposite one of depression, of suspension
of action, of paralysis."—Brit, and For. Rev., 34, p. 582. On this state of secondary
nervous depresion, he conceives that the subsequent dilatation of the vessels depends
ON INFLAMMATION.
55
ble—from both of these circumstances. But soon this spasm or increase
of tone in their coats passes off; they gradually yield before the in-
creased' and increasing Aoav, Avhile yet the rapidity of this is by no
means diminished. After a short time, the spasm has not only disap-
peared, and the Avonted capacity been regained, but dilatation beyond
the normal standard is begun. Capillaries which previously contained
but single files of the red corpuscles, now admit of them rolling through
in masses, and these come crowding in ; in consequence, vessels for-
merly invisible are now seen plainly ; and the accelerated motion of
the general current is yet unabated. In such a state of matters, it need
afford no surprise to find a tendency to unusual transudation ; in other
Avords, along with an increased circulation, comes an increase of the
ordinary function of the circulation. The blood parts with a portion of
its contents more liberally than in quiet health. The transudation may
be at first chiefly serous ; but if such action be sustained for some time,
the liquor sanguinis is found in the interstitial spaces. The natural
function of the part is exalted ; if this be secretion, the secreted fluid
is increased in quantity, yet with its normal characters scarcely, if at
all, changed. Nutrition is exalted : and the fibro-cellular tissue is fuller
than before, giving "slight increase of bulk. Thus is constituted the
first stage, Simple Vashdar excitement—not inconsistent with health, but
rather its mere exaltation—synonymous with the Vital Turgescence of
some Physiologist. The part contains an increased amount of blood ;
its circulation is unusually active, and there is a marked tendency to
increased exudation, partly serous, partly of a plastic kind.
How such a state is produced, Ave need not here stop to inquire. Ac-
cording to some, it is by an increased effort of the blood-vessels them-
selves ; while others attribute all to the blood, and to an exaltation of
the vital affinities between its own component parts, and between these
and the solids through which it circulates. It is not improbable that
both causes are concerned in the change.
The exciting cause having been removed, the action may soon sub-
side, and the part regain quiesence ; or the exciting cause remaining,
the action is sustained, yet without proceeding to a higher grade, and a
salutary result is probably secured thereby. For instance, it is by the
continuance of such simple action, that the conjunctiva resents the pre-
sence of a grain of sand, and often suceeeds in Avashing it away by the
increased effusion. But, the exciting cause remaining, or being severe
in its nature, though of brief application, there is neither abatement,
nor simple maintenance of the action, but advance ; and this brings us
to the second stage.
II.—Active Congestion.—The vascular commotion extends on the
cardiac side of the affected part; the arterial trunks feeding it have
partaken in the excitement, are begun to enlarge, and are pulsating
with an umvonted energy. More and more blood is sent doAvn to the
part, and the capillaries and minute arteries begin to give Avay beneath
their burden ; hitherto they were simply dilated, retaining their tone,
and controlling the circulation of their contents ; but now enlargment
is about to be merged in over-distention, the vascular coats gradually
parting with their tone.* And partly from this cau3e, partly on account
56
PRINCIPLES OF SURGERY.
of change in the blood itself, which seems more viscid, with its cor-
puscles less distinct, and when examined by the microscope, is found
especially to possess an increased number of colourless " lymph glo-
bules," unusually adhesive to each other and to the Avails of the ves-
sel, and so manifestly operating obstructively—and partly, also, it ia
probable, from an increase of vital attraction between the blood and
surrounding parenchyma—the circulation loses its acquired rapidity,
and becomes sloAver even than in health. The red corpuscles are no
longer limited to the central current, but are encroaching more and
more on the lateral and clear " lymph spaces." Exudation is more
copious than in the previous stage ; it consists of serum and of liquor
sanguinis, the latter usually predominating: and when the action has
been for some time sustained, and, as it were, established in the part,
fibrin alone may be deposited. The fibrin of the blood is increased,
not only in quantity, but also in plasticity, or tendency to become organ-
ized. The natural function of the part is not simply exalted, but begins
to be perverted: for example, secretion is not only increased, but
changed in its character. By the fibrinous interstitial deposit, the tex-
ture of the part is softened and enlarged. The "formative poAver," as
it is termed, of the part is impaired or overborne ; the supply of plastic
material is greater than can be usefully and normally appropriated by
the implicated tissues.f Nutrition, or the normal and vital relation
which subsists between the living tissues and nutrient materials con-
tained in the blood, is becoming more and more disturbed ; and this,
perhaps, constitutes the most important part of the inflammatory pro-
cess, leading ultimately to change of structure, more or less permanent,
and more or less inimical to resumption or continuance of normal
function.
Thus is constituted Active Congestion ; the arterial trunks in increased
play ; the amount of the blood in the part still farther augmented ; its
vessels beginning to be over-distended, and losing tone thereby ; its
circulation becoming slow ; its blood undergoing change, the fibrin
especially being increased, both in quantity and plasticity ; function
and nutrition perverted. We are leaving the confines of health, and
have, indeed, already made some progress into the territory of disease.
* " Atony and flaccidity of blood-vessels may become a cause of impediment to a
current through them, not by preventing these vessels from actively contracting on
their contents, but by removing that tone by which the vessels maintain the calibre
and the tension best calculated to transmit onwards the force of the current. Ves-
sels thus weak and inelastic, instead of equably conveying the current, become dis-
tended, lengthened, and tortuous in receiving it: and by their very mass, as well aa
by their inelasticity, they partly break the force of the current, and partly turn it
into other channels."—Williams' Principles of Medicine, p. 207.
t " The various solid tissues which are in continual process of change, more or
less rapid, derive the materials of their reconstruction from the blood, especially
from its fibrin ; which they have the power, by their vital endowments, of causing
to assume their own respective forms of organization. The vitality of the tissues in
any part may vary in its degree ; so that their formative power may be increased or
diminished. When their formative power is increased, the process of nutrition ia
performed with unusual rapidity, and the fibrin of the blood is rapidly drawn from
it; but when the formative power is diminished, the process of reconstruction ia
slowly and imperfectly performed, and the demand for fibrin is less."—Brit and
For. Med. Rev., No. xxxv., p. JOS.
ON INFLAMMATION.
67
This action may resolve after the removal of its simple exciting
cause; or it may be sustained for some time, as in the healing of
wounds, and the closing of ulcers; or it may advance to
III. True Inflammation.—The change Avhich, in the preceding stage,
had begun m the blood, is now completed. The over-distention of the
capillaries is established ; the capillary power is for a time gone—per-
haps in consequence of diminution or actual suspension of the nervous
influence ; and the coats of the capillaries and other vessels are thick-
ened, softened, and impaired in cohesion, being themselves the sub-
jects of structural change. The languor of circulation approaches
stagnation, and at some points this has actually occurred ; every part of
the distended capillaries is occupied by crowded coloured and colour-
less corpuscles ; partly, it may be, from increased attraction between
the former and the surrounding parenchyma, partly by accumulation
and adhesion of the latter to each other and to the capillary Avails.
The altered liquor sanguinis is exuded in profusion. The capillaries
also give way in their coats, and from the lesion blood is extravasated
in mass Suppuration is in progress by extravascular degeneration of
the fibrinous effusion, or else by a secretive elaboration of it ere yet it
has left the vessel. Breaking up and disintegration of texture ensue,
according to the extent of extravasation and suppuration ; and the dis-
integrated texture is commingled with the effusion. The formative
power has ceased, and the opposite condition, a tendency to disintg;
gration, from diminution of vitality, has become established. Disorder
of function is complete ; secretion, for example, being in the first place
arrested, and, when restored, more vitiated than before.
Whilst in the circulation of the part truly inflamed all is sluggishness
and stagnation, that of the parts around is unusually active. The arte-
rial trunks in the vicinity continue to play Avith increased energy; more
blood continues to be sent, but cannot now be transmitted in its direct
course : in the inflamed part it meets an obstruction, and being sent
round another way, throws a greater stress on the collateral vessels ;
these retain vigour sufficient for the augmented labour, and send the
current merrily round. But, in their turn, they themselves may be
overborne by an extension of the disease, and the active route rendered,
at each such extension, more and more circuitous.
While the apparatus of deposit is thus unusually busy, that of ab-
sorption is in abeyance. During inflammation, the lymphatics and
minute veins do either little or nothing as absorbents. • But on the
yielding of the action, not only does effusion begin to abate, but, besides,
absorption again comes into play, and that actively ; and thus the part
is often restored nearly, or altogether, to its former state. During in-
flammation of a serous membrane, for instance, a large amount of liquid
effusion often rapidly accumulates within its cavity; so long as the
act;on persists, that fluid either remains stationary or receives an in-
crease ; but so soon as the inflammatory process has fairly given way,
and resolution is in progress, the effusion plainly diminishes, almost
pari passu ; and in two days, or perhaps in but a few hours, it may have
wholly disappeared.
The inflammatory change of the blood is important. 1. The liquor
58
PRINCIPLES OF SURGERY.
sanguinis is increased in relative quantity, and its serum is said to con-
tain an unusual amount of albumen. 2. The fibrin is increased in
quantity, both actually and relatively to the red corpuscles; the vital
attraction between its component particles, tending to aggregation, ig
also augmented. During Active Congestion, its plasticity was increased,
but now it becomes more and more aplastic. The proportion of serum
is diminished, probably in consequence of effusion. 3. The red cor-
puscles are relatively diminished in number ; and their tendency to
aggregation is augmented. 4. The colourless or " lymph globules"
are greatly more numerous; but whether by neAV formation, or by mere
accumulation in the part, has not yet been determined. They incline,
not only to aggregation, but also to adhere to the sides of the vessels;
thus increasing, or according to some, causing the tendency to stagna-
tion of the blood.
a, Colourless globules adherent.
b, Blood dies, still circulating in a diminished space.
c, Dense, stagnant, homogeneous mass.
d, Corpuscles in oscillatory movement, becoming detached from the impacted mass.
Williams' Princ. of Med.
This alteration of the blood, begun in the second, and completed in
the third, or true inflammatory stage, is at first a local act, effected in
the part inflamed ; but this laboratory, if continued thus in operation
ultimately involves the whole circulating fluid in similar change '
Such is Inflammation Proper. Blood much altered ; stagnant or
tending to stagnation. The capillaries over-distended passive tubes •
their coats thick, soft, and lacerable. The neighbouring circulation'
OF INFLAMMAX'ON.
59
collateral, unsually active. Exudation of liquor sanguinis whose
fibrin is becoming more and more aplastic : extravasation, by lesion, of
blood. Nutrition and function Avholly perverted. Structure changed,
texture softened and enlarged. Suppuration in progress; and part of
the texture breaking up. Nothing healthy or consistent Avith local
health; all essentially disease.
This state is not at once established, so soon as the period of incuba-
tion has passed aAvay; but, as already stated, is approached by a pro-
cess of transition more or less gradual. The previous stages may be
either short or protracted, but can, in no case, be proved absent.
When the process is somewhat tardy, its compound nature is the more
distinct. Take, for illustration, the vaccine pustule ; an inflammation
resulting from a poisoned wound, and gradually attaining to its consum-
mation. The exciting cause is applied, and for a time seems to be in-
operative ; three days commonly elapse Avithout the appearance of vas-
cular excitement; and this is the period of incubation. On the fourth
day the papular condition is established; commencing with simple
excitement, and steadily verging towards active congestion. During
the four following days the vesicle is formed, the result of the crescent
second stage of action; the vesicle at first containing mere serum,
afterwards becoming of a more glutinous character by exudation of the
liquor sanguinis. On the ninth day the pustular formation is attained ;
and not until then has the establishment of True Inflammation been
completed. Soon thereafter the vascular action ordinarily subsides,
and the part slowly recovers.
During the morbid progress, advancement is usually at and from the
centre; and, supposing a section made of the inflammatory disc, the
accompanying diagram may conveniently illustrate the state of the part.
The outer circle representing simple vascular
excitement, whose characteristic effusion is
serous; the second, Active. Congestion, Avith
exudation of the liquor sanguinis ; within the
inner circle, True Inflammation, denoted by
more or less extravasation and destruction of
texture, and the formation of pus in progress.
Thus, True Inflammation structurally con-
sidered, consists of suppuration, actual or im-
minent, surrounded by fibrinous deposit, and
that encircled by effusion of serum.
It has often been disputed Avhether Inflammation is the result of an
increase or diminution of vital strength in the part—an excitement or
a debility ; and both extremes have been tenaciously held and argued.
According to the preceding account, the fact lies midway between the
disputant?; the action being found to commence with excitement, and
probably an actual exaltation of the part's vitality; this, however, pro-
vine usually of short duration, and succeeded by growing debility and
much ultimate prostration. Inflammation established, vital power is
sunk very low. And what is worse, from this overflow, the part, once
truly inflamed, never altogether recovers, but ever remain^both more
prone to action, and less able to control it; a fact which it is of much
60
PRINCIPLES OF SURGERY.
importance that both patient and practitioner should bear in remem-
brance.
Local Symptoms of the Inflammatory Process.
The consecutive changes Avhich I have endeavoured to describe, and
whose completion constitutes true inflammation, are ordinarily accom-
panied and indicated by certain signs ; redness, swelling, heat, pain,
throbbing, increased sensibility, disorder of function, arrest and change
of secretion.
1. Redness.—The more fully a part is injected Avith blood, the redder
is its hue. An inflamed texture, as Ave have seen, has its amount
of blood very much increased ; its colour is necessarily heightened
thereby. And not only are the vessels unusually gorged with blood;
that blood is unusually red ; much of the liquor sanguinis having moved
on from the field of actual or threatened stagnation, leaving the over-
distended vessels filled chiefly Avith an agglomeration of red corpuscles.
The cause of redness then is obvious.
The extreme vascularity of certain parts when inflamed, the con-
junctiva for example, has been supposed to depend in part on the
formation of new vessels, a result of the action. This may ultimately
be the case ; but it is not so in the first instance. Minute capillaries,
in health, carrying the red corpuscles in but single files, are invisible
to the unassisted eye; inflamed, they are dilated, burdened Avith cor-
puscles in mass, and plainly seen ; appearing to have groAvn up sud-
denly by a new creation, but being in truth only an enlargement of
texture previously existing. The formation of new blood-vessels in
fibrinous deposit, is a gradual and never an immediate process, as will
be explained in the proper place. Such ultimate vascularization is a
frequent result or attendant on inflammation, but is incompatible and
cannot be co-existent Avith the true inflammatory crisis, Avhich is adverse
to all formation of tissue, and is suppurative and destructive.
The degree of redness varies according to the intensity of the action,
and the previous vascularity of the part; or, in other words, according
t» the extent of the vascular engorgement, and the number of vessels
Avhich are engorged. It is a familiar test of the violence or forward-
ness of the disease, to look to the amount of redness. And we find an
inflamed tendon less florid than inflamed skin ; inflamed skin less red
than inflamed mucuous membrane.
The tint varies according to the character and accompaniments of
the action; a bright arterial red is exhibited by what is acute and
sthenic ; the chronic and asthenic is denoted by a dark, venous, or
purple hue ; great attendant biliary derangement giving a yellowish
red, as in bilious erysipelas. °
It is imagined also, that, during the inflammatory remora of the
blood, transudation takes place of the colouring matter from the red
corpuscles to the plasma, and also from the general mass of blood
through the vascular coats to the parenchyma ; and that to the extent of
this occurrence, the variations in the tint of an inflaming part mav ho
at least in some degree, ascribed. 'J '
ON INFLAMMATION.
61
The extent and form of redness vary; sometimes limited to but a
spot, as in the pustule or phlegmon ; sometimes occupying a large
space, as in erysipelas, and the corresponding affection of the mucous
surface. Sometimes in one unbroken sheet, as in erysipelas ; some-
times in lines or patches, as in inflammation of the veins and of the
lymphatics. _ Sometimes gradually lost by diffusion in the surrounding
paleness, as in phlegmon ; sometimes carrying an abrupt bright margin,
as in the erratic erythema.
The diagnostic character of inflammatory redness is its permanency.
Other redness may come and go, as the blush of shame, or the glow of
warmth ; but that of inflammation is fixed. By the pressure of a finger
it may be made to disappear momentarily, but the pale dimple" is
quickly filled up and colored as before ; all trace of the touch almost
instantly vanishes, like the passing of breath from a mirror. The pa-
tient may be bled to syncope, and the general surface grow pale as mar-
ble ; but this will not yet blanch the inflamed part; its redness remains
until the action which caused it shall have passed away.
But not only has it no flitting tendency; it must be conjoined with
other symptoms. The crimson spot on the hectic cheek, is fixed
there ; but there is neither pain nor swelling ; it is not conjoined with
other signs ; it is not inflammatory.
2. Swelling.—The umvonted accumulation of blood will alone occa-
sion this in the part inflaming, as is exemplified by the slight yet pal-
pable elevation of erythematous skin, ere effusion has occurred. But,
as a symptom of inflammation, it is mainly caused by escape of a por-
tion of the vascular contents into the intervascular spaces. The action
yet nascent, serum is effused ; in its second stage, the liquor sanguinis
is found, or fibrin more or less separated from its serum; and this fibrin
is of high plasticity ; in the third, the fibrinous deposit is continued, but
of impaired plasticity, and Avith it is mixed blood extravasated in mass,
the result of Avascular lesion, and ultimately purulent formation is more
or less advanced. So that, again referring to the diagram—centrally
we have a soft fluctuating swelling, Avhere there is blood and pus ; sur_
round this, a dense and unyielding circle,
somewhat diffuse, and usually less prominent
than the centre, the result of plastic fibrinous
accumulation; and exteriorly to both, a soft
pitting oedema, more or less extensive, accord-
ing as the fibro-cellular tissue has been filled
by serous effusion. The combined result is
softening of texture, and impairment of cohe-
sion as Avell as enlargement.
Swelling, like redness, will not alone indi-
cate inflammation ; it must be conjoined with
other symptoms. In simple oedema there may
be much swelling, yet there is nothing of the inflammatory process.
It is also of gradual and recent formation, not suddenly developed,
as is the bulging of a hernia or dislocation, or the sanguineous infiltra-
tion immediately consequent on a blow; nor of a tedious growth and
ancient origin, as is the genuine tumour.
6
G2
PRINCIPLES OF SURGERY.
The tendency of swelling is beneficial or otherwise, according to the
part affected. If this be internal, of delicate texture, and important in
function, swelling there may prove in the laat degree injurious, as m
the brain. Or a part, itself comparatively of little importance, may be
in the immediate vicinity of one which is of the greatest; and enlarge-
ment of the former may react on the latter most injuriously ; swelling of
the orbital cellular tissue will so affect the eye-ball; inflammatory
tumour of submucous tissue may fatally occlude a mucous outlet—as
the glottis. On the other hand, swelling is usually a fortunate occur-
rence, and encouraged as such by the surgeon ; if ihe part be situated
externally, as the ordinary subcutaneous cellular tissue ; or if it be nei-
ther itself of delicate texture, nor endowed with function essential to the
animal economy, nor closely connected with one Avhich is either or both—
as the textures occupying the inter-muscular spaces. The over-distended
vessels are relieved of part of their burden ; and an opportunity, vary-
ing according to the extent and rapidity of the effusion, is thus afforded
them of recovering from debility, regaining their normal tone, and once
more controlling the circulation of their contents. Always provided,
hoAvever, the effusion from the vessels, and the yielding of the sur-
rounding texture, to receive that effusion, advance consentaneously,
and in harmony.
Of this favourable kind are very many of the swellings in an in-
flaming part, Avith Avhich the surgeon has to deal, as in erysipelas,
phlegmon, fractures, bruise, &c. It is, therefore, an error to regard
the amount of SAvelling as a certain index to the extent of mischief; nor
ought even great tumescence to Avarrant, of itself, a gloomy prognosis.
Further, SAvelling is not to be invariably prevented, or opposed in its
progress ; on the contrary, it is often to be invited to the part, and,
when there, promoted in its advancement. We have seen that the
most prominent change effected in the blood by inflammation is in-
crease of the proportion of fibrin; this, therefore, may be regarded as
the principal inflammatory ingredient in that fluid. If much of it be
extruded from the vessels, either per se or along Avith the serum, it
were most reasonable to expect benefit from such an event. And
thus Ave may obtain another reason in favour of SAvelling as a salutary
occurrence.
The exudation of plastic fibrin will afterwards be seen to be farther
advantageous, as constituting a most important limit to the central sup-
puration, Avhen that occurs.
From Avhat has been said, it is already apparent how the tendency
of swelling is prominently connected with the texture of the part; the
less yielding, the less favourably disposed for effusion. The action
increasing, so does the escape of the vascular contents; but should the
texture refuse to accommodate this growing addition to its bulk, there
arises, as it were, a struggle betAveen the unloading vessels and the
unyielding part, the issue of which is sure to be disastrous. It is the
surgeon's office to watch this, and either maintain or restore harmony,
if possible. Otherwise, pressure from the pent-up effusion reacts dis-
advantageous^ on the blood-vessels and nerves of the part; tension
is soon accompanied by throbbing, heat, and violent pain ; the morbid
ON INFLAMMATION.
63
action has received a fresh impulse, and advances accordingly. Or
the tightness of the pressure thus caused may be so great, as to arrest
altogether the circulation in the part, already inclined to stagnation,
and so render gangrene inevitable.
Hence it is that rapid SAvelling in a loose texture tends always to
relief, as in the ordinary fibro-cellular tissue; while swelling in that
which is unyielding requires both constant and skilful care, and even
then does injury. Acute effusion in bone, beneath a tightly spread
fascia, or between bone and its fibrous periosteum, are occurrences
invariably severe, and prone to result in destruction of texture. Acute
action, Avith rapid effusion in and beneath the sclerotic conjunctiva, is
comparatively harmless; while, in the cornea, the result is usually
gangrene.
3. Heat.—This is a symptom seldom absent or devoid of promi-
nence. And it is easy to imagine hoAv it should be so, Avhen we
remember that the part inflaming has an unusual quantity of blood sent
through and around it; and that this blood, both while threatening to
stagnate and Avhile coursing rapidly past the obstructed part, is under-
going serious change. From this cause the temperature is necessarily
elevated somewhat above its former and ordinary range, as is apparent
to the touch. But nerves of sensation, partaking in the general disorder
of the part, have, in consequence, their functions excited and perverted.
In truth, increased sensibility is one of the signs of inflammation ; and
Avhen Avith that Ave couple the circumstance of an unusual amount of
changing blood giving an actual elevation of temperature, avc can
readily understand how the patient should feel a greater heat than the
thermometer Avould indicate. The heat of inflammation, therefore, is
partly actual, as ascertained by the touch or thermometer,* partly the
result of a perverted nervous function, estimated only by the patient.
Heat, like redness—and as Ave have seen, both partly depend on
the same cause—to be inflammatory must be permanent. Blushing
brings heat as Avell as colour ; but both are evanescent. It is also con-
joined with other symptoms of the perverted action ; in hectic, there is
often a constant burning in the hands and feet, yet no inflammation is
there.
4. Pain.—Of all the symptoms of inflammation this is probably the
most characteristic ; yet pain is not unlikely to deceive.
Nerves of sensation, in the part inflaming, have, as already stated,
their function excited and perverted; they are compressed by the dis-
tended vessels, more especially when lodged in the same fibrous sheath ;
and such pressure is most materially increased by the advancing effu-
sion, particularly if this be situated in an unyielding texture. Besides,
at each throbbing impulse of the blood, the arterial vessels, themselves
altered in their coats, undergo, not only dilatation, but elongation; from
this the nervi vasorum must, more or less, suffer, and they contribute
something to the general amount of pain. That pressure is perhaps
* The natural temperature of the body varies from 9So to 100°, at the heart and on
the trunk, and is about 92° at the extremities. In parts inflamed the thermometer
has indicated a rise to 101°, 104°, 103°, and even J07o, of Fahrenheit.—(Article, In-
>lammati»n, Cyclopaidiu of Practical Medicine, p. 73;;.)
64
PRINCIPLES OF SURGERY.
mainly concerned in the production of the pain, may be inferred from
the fact, that this svmptom is invariably aggravated, and chiefly felt,
when compression of the part inflamed is increased—as by the hand in
peritonitis, or by inspiration in pleurisy.
Such causes are liable to vary, and so is their result. The pain of
inflammation is not uniform, but influenced by the intensity of the action
and the nature of the part affected. The higher and more rapid the
action, costeris paribus, the greater the pain. A part originally sensitive
gives forth much more inflammatory pain than one naturally dull—even
although under a less amount of action ; an erysipelas limited to the
true skin, and tending only to serous effusion, is far more painful than
a suppuration of the cellular tissue. As formerly stated, pain is much
regulated according to the power of yielding in the part, to accommo-
date effusion; inflammation of bone is more painful than inflammation
of skin; erysipelas more painful than inflammation of mucous mem-
brane ; inflammation of serous and fibrous tissues more painful than
either.
Pain is not always inflammatory ; it may be the attendant on spasm,
or on simple irritation. The pain of spasm is intensely violent from
the very outset; and though often abating more or less during its stay,
seldom advances to a higher degree than that with which it began.
The pain of inflammation, on the contrary, usually commences with a
slight amount, and steadily advances, hourly increasing, until either
the action is subdued or the part has perished by gangrene. Pain of
spasm is often relieved by pressure; at all events, is not aggravated
thereby. In inflammation, pressure, even slight, is quite intolerable.
In colic, a man is gratified by a weight upon his belly ; in peritonitis,
the slightest touch is torture.
In neuralgia—an example of irritation—pain is severe at its first
onset, like that of spasm; it remits much and variously during its
course; and often intermits Avholly, during intervals more or less
prolonged. The pain of inflammation may remit, but only slightly;
and is never intermittent. It may disappear suddenly ; but if so, is not
likely to return—the part having, in all probability, ceased to be
amenable to farther vital change.
The characteristics of inflammatory pain, then, are—it usually com-
mences in a comparatively slight form, and steadily increases; it is
constant, until either the action resolve or the part die ; and it is inva-
riably aggravated by pressure.
Sudden disappearance of inflammatory pain is ahvays fraught with
suspicion. It is inconsistent with its ordinary character, growing
steadily as the action advances, and subsiding as it recedes. In a
neuralgia, excruciating agony often ceases in an instant, for some
hours is wholly absent, and then probably returns as violent as before.
Such is its ordinary character and tendency ; but not so with inflamma-
tion. On its abrupt cessation, Ave do not dream of a mere remission
of its cause, but suspect, and too often with truth, that the part is no
longer capable of sensation, and has lapsed into gangrene. For exam-
ple, a portion of bowel is acutely inflamed, connected with hernial pro-
trusion or not; the pain is excruciating ; on a sudden it ceases and
ON INFLAMMATION. 65
the patient gratefully expresses his relief, and thinks he is better, per-
haps safe ; the surgeon, on the contrary, is alarmed, and looks to the
pulse, the surface, and the face ; he finds them feeble, cold and clammy,
and collapsed ; the part has mortified.
In inflammation, pain is sometimes absent, or, as it Avere, latent. An
acute abscess may have formed in a limb previously paralytic, deprived
of sensation as well as motion, and the patient's attention may have
been scarcely attracted to the part by the perception of aught unusual.
Or an injury of a limb has been accompanied by affection of the brain,
inducing coma, perhaps long continued; in the limb inflammation may
be advancing destructively, yet pain is neither felt nor evinced by the
sufferer. In such cases the surgeon has to feel for his patient, and in
the absence of his pain, be unusually attentive to the other symptoms
of local disorder.
The pain sometimes may be termed sympathetic ; referred to a part
at a distance from that in which the inflammation resides. Such a
part is either connected intimately by function Avith the other; or it
contains the terminal expansion of nerves Avhose trunks pass through
or near the inflammation. Thus we may have suppuration in the hip-
joint, causing infinitely less pain in that articulation than in the region
of the knee ; abscess of the liArer producing pain in the shoulder;
inflammation of the kidney causing pain at the orifice of the urethra.
It is of the utmost importance that the practitioner bear this in remem-
brance ; otherwise he may be leeching the knee, instead of the hip ;
rubbing the shoulder, instead of attacking the liver ; looking for the
outbreak of a gonorrhoea, instead of opposing a renal malady, which is
soon to bring life into imminent peril.
Pain is of itself a formidable thing; if intense and constant, certain
to exhaust the poAvers of life : and in consequence, in many inflamma-
tions, it must be overborne at whatever cost. When the part inflamed
is an internal organ, intimately connected Avith the ganglionic system
of nerves, the pain is of a peculiarly depressing nature, and highly
dangerous by continuance. But ordinarily the attendance of pain on
inflammation, unless severe, maybe viewed rather as of a salutary ten-
dency. Were the action painless, practitioner and patient might be
unaware either of its existence or of its extent until too late to save
texture, function, or even life.
When inflammation is the result of direct application of an exciting
cause, as wound, heat, or acrid substance, pain usually precedes the
vascular action ; an immediate effect on the nerves of sensation. This
may continue, more or less, and be merged in the inflammatory ; _or
may soon eease, leaving the greater portion of the period of incubation
comparatively free. Such pain is also not without its use, leading to
precautionary and preventive measures—often more valuable than the
curative. .
5. Throbbing.—This is the result of obstructed circulation in the
part; and will not occur, at least to any extent, until the action shall
have reached the period of sanguineous stagnation. Expose the femo-
ral artery, and its play seems even and gentle; but place a ligature
around it, and on the instant the blood beats tumultuously on the distal
6*
QQ
PRINCIPLES OF SURGERY.
aspect, as if angrily labouring to overcome the obstructing cause.
The inflammatow process begun, the arterial trunks in the neighbour-
hood are found acting with unwonted energy in bringing down the in-
creased supply, as yet free in its course ; this may be felt by the ob-
server, and also by the patient, but is often unappreciated by the latter ;
the sensation of throbbing is then either absent or slight. But when
there is not only an increased supply, but also obstruction to its direct
transmission, a threefold energy seems to be demanded of the arteries,
in bringing an unusual load, propelling it by a circuitous route, and
struggling against the obstruction Avhich lies directly in the Avay, Such
action is felt by the patient, and that distinctly. Throbbing is thus
readily accounted for in the part, and in the arterial trunks leading to
it; the amount varying according to the degree of obstruction and the
intensity of the action which has produced it; also modified by the
texture of the part affected.
Experience teaches that, when there is much throbbing attendant on
inflammation, suppuration is likely to ensue. It is easy to imagine how
this should be so, in a part with its direct circulation much depressed,
and its collateral much increased, effusion copious, and extravasation
by lesion imminent. Throbbing, and a tendency to suppuration depend
on the same cause.
Throbbing is painful; at each pulse the patient's sufferings are in-
creased. It is then that the nerves, already tightened in their place by
the circumjacent effusion, are most severely compressed ; and it is then
that the vascular coats, themselves disordered, are stretched as well as
dilated.
6. Increased Sensibility.—This is the result of perverted nervous
function. The eye, when sound, bears a flood of light with impunity;
inflamed, it winces under the faintest ray shot directly upon it. The
skin, in its healthy state, bears much manipulation ; in erysipelas, the
slightest touch is resented. The stomach in health neither rejects food,
nor does sensation of discomfort indicate its presence; yet the same
organ, becoming inflamed, is intolerant of the simplest ingesta. The
bladder ordinarily aAvaits its full distention by urine; in cystitis, the
smallest accumulation is urgently expelled.
Obviously this is also a wise and beneficial arrangement. Rest, as
we shall see, is one of the most important means Avhereby inflammation
may be met and subdued ; and intolerance of function is effectual, not
only to suggest the propriety of rest, but also to compel its adoption.
How lamentably destructive might not inflammation prove were it un-
accompanied by pain and increased sensibility !
7. Disorder of function, invariably attends, more or less, on the in-
flammatory process ; the degree of disorder usually keeping pace with
the progress of the action. At first, there is excitement or increase of
the normal function, synchronous with simple excitement of the part •
then perversion of function, corresponding with the second stage of
action, when delay of the blood is begun, and extra-vascular deposit is
copiously advancing. Ultimately, function is depressed ; and probablv
arrested m that part where the true inflammatory crisis has been at-
tained, the blood stagnating, and structural change fairly established
ON INFLAMMATION.
67
On subsidence of the action, function is resumed ; but when resumed,
is for some time more perverted than previous to its arrest; and may
slowly if ever return to its pristine and normal character.
The stomach, inflaming, ceases to be useful as a digestive organ ;
the kidney, as an uropoietic ; the bladder, as a receptacle of urine ; the
brain, as an organ of sense and intellect; a muscle or bone as an organ
of locomotion ; an artery or vein, as an organ of circulation; an eye
or ear fails in its special duty.
Exaltation of function followed by depression is well exemplified in
the case of the internal organs; the heart, or other contractile fibre,
inflaming, at first acts with increased energy, but subsequently with
feebleness and irregularity; in regard to the brain, Ave have first de-
lirium and convulsions, then coma and paralysis; " in the early stage
of inflammation of the spinal chord, there may be tetanic convulsions—
afterwards follows paralysis."
But perhaps the most obvious illustration of this symptom is as re-
spects secretion—say from a mucous membrane—as in a nascent gonor-
rhoea. At first the ordinary mucous secretion is augmented, probably
in a diluted form, containing an unusual amount of serum ; then it
groAvs less copious and more glutinous, the liquor sanguinis contributing
more to its formation ; by and bye it changes still more, and has a puri-
form or milky appearance ; and soon it is altogether arrested, the dry
mucous lips then bearing more redness, swelling, pain, and heat than
before. But true acute inflammation cannot long persist without in-
ducing either ulceration or gangrene; the action gradually declines,
and the part is moist again; at first, perhaps, blood escapes, or this
may happen previous to declension ; then suppuration, real or apparent;
then the glutinous and the serous fluids once more ; and ultimately the
settling down to the ordinary mucous secretion. Or malapraxis may
carry the illustration a step further, by repetition. At an early period
of the disease, while matter is flowing in profusion from the orifice, an
intensely strong injection is applied—not of the nitrate of silver ; the
discharge is speedily arrested ; but the disease is not cured—for the
ordinary signs of inflammation are aggravated, and the discharge now
reappears more copious and inveterate than before. The action had
begun to decline, but the ill-advised remedy, acting as a fresh exciting
cause, brought back the true inflammatory crisis.
Extension of the Inflammatory Process.
The inflammatory process may extend, 1. by continuity of the in-
flaming texture ; and certain textures are peculiarly prone to such
extension—as the skin and mucous membrane. It is no uncommon
thing to find an inflammation of skin, the result of injury, and at first
a mere pustule, spreading continuously into an erysipelas. And per-
verted vascular action, at first limited to one portion of mucous mem-
brane, often quickly spreads over a large space of the same tissue ;
from the fauces to the larynx, trachea, bronchi, and bronchiae; from
the pharynx to the oesophagus ; from the stomach to the boAvels; from
the vagina to the urethra; from the urethra to the bladder.
68
PRINCIPLES OF SURGERY.
2. By contiguity ; the textures successively involved, not being con*
tinuous, but connected by juxta-position ; and usually, the mope loose
the intervening texture, the greater the facility of extension. In neg-
lected phlegmonous erysipelas, the action commencing in the surface
may soon reach bone and joint; inflammation of a mucous membrane
often induces abscess on its exterior, as in the case of the urethra;
action, originating in the envelope of an organ, may pervade the organ
itself.
The more rapid the attainment to the true inflammatory crisis in the
par,t first attacked, the more likely is the action to extend, and that
quickly, to those in the neighbourhood; its advance is unopposed by
attendant change of structure. In the formation of an ordinary acute
abscess, the progress is gradual, and the central portion truly inflamed
is surrounded not only by serous effusion, but by a mass of dense
fibrinous deposit, filling up, and as it Avere, fortifying the previously
loose tissue, and exciting a restraining influence on both the extension
of the disease and the diffusion of its products. In phlegmonous
erysipelas, on the contrary, the crisis is much more speedily effected,
there is no such salutary barrier, the surrounding texture remains open
to both extension of inflammation, and the diffuse infiltration of matter;
the consequent mischief is great and often irreparable. The limiting
fibrin is either not deposited ; or, as more frequently is the case, the
exudation is of an aplastic kind.
Many other examples might be given of the advantage derived from
true inflammation being preceded by active congestion ; suppuration
being surrounded and limited by plastic fibrinous deposit. Often the
texture and efficiency of an internal organ are thus saved; as well as
the irruption of pus into an internal cavity prevented, perilling life
either by compression of some neighbouring part, or by violent inflam-
mation of the cavity's lining membrane.
3. Extension of the inflammatory process may be remote—that is,
the part secondarily involved is at a distance from the original site of
action ; and the intervening parts are unaffected. This may be effected
by 1. the blood. This fluid, as formerly seen, emerges from the inflaming
part, changed, as from a laboratory ; and circulating thus altered to
other and distant parts, may itself become the exciting cause of per-
verted vascular action there. Purulent formations—in fact, unusually
(acute abscesses—occurring in certain forms of phlebitis, at a distance
ifrom the affected vein, may be thus satisfactorily accounted for. 2. By
the agency of the lymphatics. A part is inoculated by a hurtful virus
and inflammation results in the wound; besides, a portion of the virus
has been carried on by the absorbents, not only contaminating the sys-
tem thereby, and so establishing constitutional disorder, but lighting
fresh fires in its inward track—it may be while the conducting appara^
tus is almost or altogether unscathed. Thus-a poisoned wound of the
finger gives first superficial paronychia, and then abscess of the axilla
often without apparent affection of the intervening lymphatics When
they suffer, the case is plainly an example of continuous, as well as of
remote extension.
By nervous agency. By this, sympathy of function is maintained
ON INFLAMMATION.
69
between distant parts in health ; by the same agency, sympathy of action
may be established in disease. Thus, morbidly as Avell as ordinarily,
the uterus is found sympathizing with the inamma ; the testicle with
the urethra ; the kidney with the bladder.
Constitutional Symptoms.
But the disease extends not only from one part to another, but also
from a part to the system. It seems not unreasonable to suppose that
the arterial excitement, Avhich Ave find so plainly marked on the cardiac
aspect of an inflamed part, should extend centripetally, ultimately
reaching the heart, and so induce an exaltation of the whole circulating
function. But the constitutional involvement is not from mere exten-
sion by continuity, as will be immediately explained. The blood, we
have seen, undergoes serious change in the part inflamed ; and by a
constant succession of such changes, the whole fluid comes at length
to be altered almost to the same extent as that portion of it Avhich has
just emerged from the seat of local action. Draw blood directly from
the part, as well as at a great distance from it; and the two fluids will
be found exhibiting nearly the same characters of change. Its coagula-
tion is generally slow, and results in a clot unusually dense, surrounded
by serum, apparently increased in quantity, because thoroughly squeezed
out of the solid matter. In the clot the fibrin and colourless "lymph
globules," increased both in quantity and in tendency to aggregation,
go together; separating from the red corpuscles, probably diminished
in number, but having also their tendency to cohesion augmented ; the
red corpuscles occupy the loAver plane, the fibrin and " lymph globules"
the upper—rendering the surface of a yelloAvish hue ; and hence to such
blood the term " buffed" is ordinarily applied. But the increased
aggregation in the fibrin not only leads to separation from the red cor-
puscles ; it causes contraction of the buffy layer. The contraction being
centripetal, the circumference of that layer leaves gradually the sides of
the recipient vessel the weight of the general clot at the same time
dragging on the centre, a hollowing of the fibrinous surface is effected;
and the blood is said, in consequence, to be both " buffed and cupped."
The coagulum is usually of the form of an oval, truncated at both
extremities; Avith its base broader than the top, and often adherent to
the bottom of the vessel. Slightly buffed, the clot is usually cylindrical,
and floating.
Such are the appearances of inflammatory blood draAvn in mass. If
it be taken in a full stream, into a deep vessel, exposed to Avarmth,
these appearances are favoured : a tiny trickling stream, a shallow ves-
sel, and exposure to cold, are, on the contrary, unfavourable to their
occurrence. Also, at different times of bleeding, and even of the same
bleeding, such characteristics may vary ; the portion first drawn may be
neither buffed nor cupped, while that Avhich flows last is both, and
intensely so. When the blood is but slightly changed, it is said to be
sizy.
But it is not essential to have the blood in mass. A thin film, as on
a plate, exhibits a similar change. The separation between the fibrin
70
PRINCIPLES OF SURGERY.
and colourless particles is effected laterally, instead of vertically, as in
the mass ; breaking up the homogeneity of the film, much more than in
healthy blood, and giving it a spotted or mottled appearance, equally
characteristic with the cupped and buffy coat. In a thin film of healthy
blood, an appearance of speckling occurs, but only after some time has
elasped ; in buffy blood, the change is immediate and most distinct.
This renders us independent of form in the recipent vessel.
Further, the same information may be obtained from a drop as from
a film ; by the aid of the microscope,* the corpuscles are seen collecting
themselves into rolls, Avhich assume an areolar arrangement, leaving
wide interspaces for the fibrin, " lymph globules," and serum. Even
the eye, unassisted, observes the mottling thus caused ; and so we arc
made independent of quantity as well as mode of abstraction. We may
be very anxious to know, whether the blood will present the inflamma-
tory characters or not; and yet the case may be one of such doubt and
difficulty, as to make us very unwilling to encounter the risk of taking
blood in any considerable quantity unnecessarily: such risk need not
be run : a drop suffices.
But it must ever be remembered that the buffed appearance is not of
itself a sure indication of inflammation. It may be seen in blood draAvn
from chlorotic,f as well as from pregnant females'; from patients affected
by sanguineous plethora, or from any one Avhose circulation has been
much accelerated, as by violent exercise. And, on the other hand,
we know that an active and most serious inflammation may be present,
while in the blood the ordinary inflammatory characters can be but
faintly traced. These are but the exceptions, however, strengthening
the general rule. Yet exceptions all important to the practitioner; in-
asmuch as, Avhile the presence of the buffy coat alone will not warrant
him in reckless expenditure of blood, neither will its absence, during
urgency of other symptoms of inflammation, be a sufficient excuse for
withholding the lancet.
Again, both the buffed and cupped appearances vary according to
the texture involved. Perverted vascular action in the fibrous tissue,
as in rheumatism, invariably presents a high degree of change ; while
a much more formidable action may be advancing in the parenchyma
of an internal organ, the change of whose blood is comparatively trivial.
* Wharton Jones, Ed Medical and Surgical Jour-
nal. Oct. 1843, p. 309.
t Arrangement of fibrin to constitute the buffy coat
does not depend so much on actual increase of the fibrin
as on its proportional excess over the red corpuscles,
in chlorosis, the latter are very much diminished in
quantity, while fibrin may be tolerably abundant.
The simply febrile condition is not capable of esta-
blishing such proportional excess of fibrin : a local in-
flammauon must be present ; that is the laboratory
whence the change issues ; without it, as in ordinary
fever, fibrin is deficient both actually and relatively.
/
'C^^^"^
On inflammation. 71
Inflammation of a serous membrane gives much of the buffy coat; less
will come from a higher action in a mucous expansion.
In inflammation Ave have thus an unusually active circulation of a
deteriorated fluid ; and it need not surprise us to find the important
vital organs impaired in function in consequence. All are more or less
disordered ; and the state of Fever is established.
The first effect of a changeoTcitculation of a changed blood, is proba-
bly on the nervous system, exerting a depressing, or poisonous influence
thereon. This, again, would seem to react, also caressingly, on the
circulating system ; accounting thereby for the premonitory symptoms of
shivering, a pale anserine skin, lowered pulse—frequent and small—
and a feeling of coldness. Soon, however, the circulation rallies, and
then commence the ordinary symptoms of Inflammatory Fever. Thus,
in the general as well as local symptoms of the inflammatory process,
the initiative would seem to belong to the nervous system—excitement
in the one case, depression in the other.
The period of incubation may be said to exist during the symptoms
of depression; but, more properly, it is considered to terminate with
them ; beginning so soon as the local inflammation—the fever's exciting
cause—has been established.
Sometimes the fever and local inflammations have almost or quite a
simultaneous origin. It is probable that in such cases, the causes of
both are the same ; system and part suffering alike, at the same time,
and from the same stimulus. But usually the fever is somewhat sub-
sequent—days may elapse, or not an hour ; obviously much influenced,
if not really caused, by the changes which the local action is gradually
effecting ; growing with its groAvth, and declining on its decay. It has
been objected to such relation, of cause and effect, that fever occasion-
ally precedes local inflammation. This is most true, but admits readily
of other explanation. The antecedent disturbance of the system is a
simple pyrexia, and does not assume the inflammatory type, until local
inflammation has been established. Erysipelas is generally ushered in
by fever; and this fever is often present, ere there is yet a blush upon
the skin ; but until the skin, cellular tissue, or both have begun to be
inflamed, that fever has not the inflammatory characters; but is an
ordinary simple fever, usually dependent on disorder of the primae viae.
In inflammatory fever, there are first the symptoms of depression
already noticed; the patient feeling much discomfort, and yet unable
to specify his ailment. A rigor, or fit of shivering occurs, folloAved by
a sensation of much heat over the ay hole surface. This is the harbinger
of reaction ; the mark—and a practical one of great importance—that
the system has shaken off the temporary depressing influence, and is
rousing itself into energy of action. Then it is that remedies are of
most avail; that opportunity, Avell taken advantage of, is usually at
once decisive of a fortunate issue ; permit it to pass unemployed, and
the same remedies, increased even tenfold, may fail to avert disaster.
It is convenient to consider the disorder of the general frame, accord-
ing to the systems.—1. The Nervous. There are aching dull pains in
the loins and limbs ; there is restlessness, and in much discomfort a
variety of posture is practised in vain search for ease; both the will
72 PRINCIPLES OF SURGERY.
and the power of exertion are diminished; anxiety, or foreboding of
evil, is felt, and its expression is given by the features ; the head gene-
rally is hot; at first special sensation is exalted ; by and bye the intel-
lectual functions are more or less disturbed ; ultimately delirium ia
established, and coma may ensue ; the face is flushed, the eyes suffused,
the skin hot and dry.—2. The Vascular. Disorder here is chiefly
indicated by the pulse. It is increased in frequency—ranging from 80
to 130 or more ; the heart's action is more rapid. It is hard, rolling
like a cord below the finger, and yielding but little to its pressure ; the
arterial coats are exercising an increased amount of tonicity, and resist
the sanguineous impulse ; usually such resistance is unequally exerted
at different points, causing irregularity of movement in the artery, and
thus a thrill or jar is imparted to the finger. It is increased in fulness,
as if the vessel Avere itself enlarged, and held a larger gout of blood at
each impulse ; the heart is acting not only more rapidly but more
poAverfully than in health ; the circulation is truly accelerated.* Such
are the ordinary characteristics of the inflammatory pulse ; frequency,
hardness, thrilling, fulness. The three first are seldom if ever absent;
the fourth may be Avanting, and the pulse small instead of full. This
modification is chiefly observed during serious inflammation of impor-
tant internal organs, more especially of those situated in the abdominal
region ; and hence it is in practice sometimes termed the abdominal
pulse : the artery resembling a hard thrilling thread rather than a cord.
It may be that the tonic contraction of the middle coat is unusually
great; or that the ganglionic system of nerves being prominently impli-
cated by the local action, a depressing influence is thence exerted on
the heart's action ; or both of these circumstances may be in operation
simultaneously. But the pulse may be otherwise modified.' An affec-
tion of the brain may be present; the patient may be laboring under
coma; and thence will come a depressing influence on both cardiac
and arterial action ; the pulse will be, comparatively, both soft and
slow. There are idiosyncrasies also to be taken into account; the pulse
may be naturally sIoav or rapid—50 or 90 ; and this must be allowed
for, when previous inquiry has satisfied us that the patient is the sub-
ject of such peculiarity.—3. The Respiratory. Respiration is quickened;
the breath is felt hotter than usual; and an oppression is complained of
in the chest.—4. The Digestive. The tongue may vary in its appear-
ance. It may be either loaded, Avhite, and moist; or loaded, white,
with its edges and central tip red and dry ; the latter is probably the
more frequent combination. Dryness is complained of the mouth.
There is thirst, usually very troublesome; nausea, loss of appetite,
sometimes vomiting, and often tenderness of the epigastrium; the
bowels are constipated.—5. The Secerning. The secretions and excre-
tions in general are materially diminished.! The bowels, we have
* Mere frequency of pulse is not a proof of increased rapidity of circulation ; the
heart's action may be weak as well as quick ; it often is so, (but not in inflammation,)
propelling the blood more slowly than in health. To expedite the flow, it must act
not only more quickly, but more forcibly, than in the normal state.
t It has been supposed that at the commencement, if not throughout, the fever, the
general capillary system is in a state of contraction or spasm ; like the capillaries of the
inflamed part at the outset of the local action. This would account for the drying up of
ON INFLAMMATION.
73
seen, are constipated ; mainly from want of mucous secretion from their
lining membrane ; the skin is hot and dry ; the mouth is parched ; the
urine is scanty, high coloured, and acrid, but little aqueous, and hold-
ing much saline matter in solution.—6. The Nutritive. Digestion is
interrupted, so is assimilation ; the inevitable consequence is, that as
the fever advances, so does emaciation, and strength is more and more
prostrate.
Such are the ordinary symptoms of inflammatory fever. The more
intense the action, and the more important the part involved, the more
rapidly and formidably are they developed. They also vary according
to the natural temperament of the patient. They may remit; nay, often
do—at one time increased, at another mitigated—exacerbation usually
vesperal, remission matutinal; but they never undergo an actual inter-
mission—therein resembling the local symptoms of the malady.
Having reached a certain point of intensity, they may decline, like
the local action which caused them. The pulse becomes less hard,
full, and frequent; the heat and thirst diminish ; strength and appetite
begin to come again ; and the secretions re-appear. Not unfrequently,
such amendment is ushered in, if not at least partly caused, by sudden
and great exaltation of the secernent function—so marked, as. usually
to be termed critical. The patient is bathed in a profuse and sustained
perspiration ; or. diarrhoea occurs ; or the urine flows copiously, more
aqueous, less saline, at each evacuation less and less coloured, and
on cooling, letting down a large quantity of sediment—resembling
brick-dust, and hence termed lateritious—composed chiefly of urate of
ammonia, more or less coloured by purpuric acid. Hence the state of
the urine comes to be important to the practitioner ; scantiness, acridity,
and want of deposit denoting persistence of the symptoms ; profuse flow
and copious sediment, declension. Or a discharge of blood takes place,
by the rectum, the urethra, the mouth, or the nose, according to the
part affected. This is not unlikely to frighten the patient and his
friends, and may alarm the practitioner ; but the latter is highly culpa-
ble who, from such alarm, rashly interferes to stop the flow ; his duty
is to Avatch the event; Avithholding his hand, unless the bleeding should
threaten to prove excessive. Such critical evacuations and discharges
are usually preceded by rigor and exacerbation—(then, too, let the
practitioner wait, and beAvare of officious meddling)—followed by
marked relief of all the symptoms.
But these, instead of declining may advance ; and, combining per-
sistence Avith intensity, may cause a fatal result. Protracted exercise
of a muscle ultimately exhausts the irritability of that muscle, Avhich
then ceases to obey the stimulus. In like manner, the excitation of
the general system is certain, if both great and prolonged, to wear out
the powers of that system; and the patient sinks in consequence.
Or the symptoms neither simply decline, nor simply advance, but
secretion, and also assist in explaining the tumult and labour of the general circula-
tion.—Alison, Outlines of Pathology, p. 138. The want of secretion and excretion,
from whatever cause directly arising, obviously tends to maintain the oppression of
the heart and arteries, by, as it were, shutting the door to the ordinary means of
relief.
7
74
PRINCIPLES OF SURGERY.
undergo change. 1. On the occurrence of suppuration, profuse and
lono--continued%r in an internal and important organ, or in a patient
previously much debilitated, they change their character, and are
termed hectic fever. 2. On the occurrence of mortification, extensive,
in an internal and important part, or in a Avorn frame, they change to
the typhoid form, tending to fatal collapse.
Causes of Inflammation.
The causes of inflammation used to be divided into, 1. Predisposing;
2. Exciting ; 3. Proximate. But as the last is really the thing itself—
the nature and phenomena of the action, already considered—we have
to do only with the first two.
I. Predisposing.—These may act through the general system, or
directly on the part itself, or in both Avays. 1. Unwonted excitability,
may reside in a part or in the system, by exaltation of the nervous
function. When occurring locally, it manifestly predisposes to inflam-
mation, Avhose first movement is an impression made on the nerves by
the exciting cause. By strained use, for instance, the eye has its sen-
sibility exalted, and the induction of ophthalmia so favoured. 2. Ple-
thora, may be general or local. The former—either the result of
original temperament, or casually induced, as by excess in diet—may,
by the abundance of material Avhich it supplies, favour increased flow
of this to any particular part, and so facilitate the induction of inflam-
mation ; but it is probable that it does not act so often or so much in
this manner as is generally supposed ; the blood itself is not predis-
posed—its red globules are in excess, not the fibrin. But there can be
no doubt that local plethora—that is, determination of blood to a part—
hoAvever induced, predisposes, and that strongly, to inflammation—
whose first movement, after the nervous impression, is this very san-
guineous determination. Increased and sustained use of a part—as of
the eye, kidney, liver—both heightens its sensibility, and brings to it
a determination of blood ; and thus doubly predisposes to inflammation.
It is familiar to all hoAv every organ thus exercised is prone to be
inflamed. It may be farther observed, that local plethora, with the
disposition to perverted vascular action which it engenders, has an
important relation to age. In infancy and childhood, the brain is
peculiarly liable to suffer ; in adolescence, towards puberty, the pul-
monary organs ; in the adult, the abdominal. 3. Debility, general and
local. This is by far the most prolific class of predisposing cases. A
vital power or strength resides inherently in the system, and in parts of
that system, Avhereby morbid action, resulting from the application of
an exciting cause, is either resisted successfully and averted, or, when
commenced, is controlled and modified. The greater the impairment
of this vital power, the more prone are system and part to the occur-
rence of disease. Inflammation thus often predisposes indirectly to
inflammation. A part inflamed, we formerly saAV, has its vital power
impaired, and never wholly regains it; it remains Aveak, and conse-
quently predisposes to recurrence of the action; sure to be overcome
by even a slight exciting cause, whose stimulus it could previously
have borne with impunity. Bad food, air, and clothing; intemperance;
ON INFLAMMATION. 75
excessive and habitual exertion of mind or body ; excessive and habitual
evacuations ; previous disease, and often the treatment necessary for its
removal—are familiar examples of causes of debility, and consequently
of predisposition to inflammation.
The predisposing causes may be combined. An eye, for instance,
may have a determination of blood towards it, at the same time that its
sensibility has been exalted by unwonted exercise of function ; at the
same time, by a previous inflammation, the part is weak; and by con-
finement, bad air or food, sustained mental exercise, or all together,
the frame also is debilitated. A part thus unfortunately situated can
scarcely avoid a high and injurious action.
II. Exciting.—Those Avhich directly induce the morbid action. The
more prominent may be shortly mentioned in detail. 1, Ordinary
irritants; as acids, alkalis, many salts, alcohol, turpentine; acting by
direct stimulus on both nervous and vascular systems of the part. 2.
Wounds, and other mechanical injuries, require a certain amount of
vascular action for their cure ; not unfrequently that action is by cir-
cumstances carried beyond Avhat is simply salutary, and prolonged into
true inflammation ; suppuration is established, and the process of heal-
ing delayed until the action shall have again subsided from the inflam-
matory acme. 3. Lodgement of foreign bodies. A wound is not
unlikely to inflame ; but if it contain extraneous matter, which is not
removed, inflammation is inevitable—the result of prolonged application
of stimulus. 4. Pressure, in like manner, is a prolonged stimulus ; if
slight, the absorbent system may be chiefly excited, causing simple
absorption; if severe as Avell as sustained, the nervous and vascular
suffer as Avell—inflammation is produced, and may cause true ulcera-
tion or even gangrene. 5. Heat is a most powerful agent. Extreme,
it may at once reduce the part to the form of a dead eschar: applied
more leniently, it proves a stimulus to both nerves and blood-vessels,
inducing perverted action of the latter, varying from simple excitement
to the most intense inflammation. 6. Cold, considerable and sustained,
may act, as an excitant of inflammation, either on the part itself, Avhose
temperature is diminished, or on some other at a distance. (1.) At a
distance. Cold is applied to the feet and legs, or to a large part of
the general surface. Circulation is enfeebled there, as shoAvn by the
pale and shrunken integument. The blood, instead of being equably
distributed over the body, is pent up Avithin, and overloads the internal
organs; one of these—the lungs, for example—is more burdened, or
more susceptible than the others ; it has obtained the first vascular move
for inflammation ; that process is begun and advances. (2.) On the
part itself; not by the first effect of the cold, but by reaction following
upon this. While decrease of temperature is maintained in the part,
comparatively little blood circulates therein, its nervous influence is
depressed, and all vital power, as well as action, is enfeebled. On
withdrawal of the cold's influence, blood rushes back to the compara-
tively empty capillaries; nervous agency is restored with a tingling;
simple vascular excitement, or in other Avords, the first stage towards
inflammation, is at once established, and that in a part Avhose vital
power has just before been impaired, and which, consequently, is but
76
PRINCIPLES OF SUPvQERY.
little able to resist or control the action so commenced; this advances
comparatively unopposed, and the part may fall an easy prey to inflam-
mation. The onset of inflammation will of course be more rapid and
severe, if the cold be not merely removed, but heat, friction, or other
stimuli, at the same time applied ; nothing can be more injudicious, yet
there are few practices more common ; grave inflammation is rendered
inevitable. 7. Atmospheric change, may either predispose or excite ;
the former, when the exposure is general and habitual—usually asso-
ciated Avith habits of intemperance ; the latter, when exposure is partial
and sudden. It is familiar to all hoAV often inflaming throats, eyes,
lungs, and joints, are attributable to casual exposure to atmospheric
vicissitude; the modus operandi is similar to what has just been ex-
plained in regard to cold. 8. Undue exercise of function, in like
manner, may either predispose or excite ; according as it is moderate
and habitual, or casual and excessive. It operates by inducing local
plethora, at the same time exalting sensibility; not only inviting the
action, but giving the first move in its advance. 9. Vitiated secretion
acts as a direct chemical irritant; (1.) from one part to another, in the
same patient, as tears to the cheek, discharge from the rectum and
vagina to the cleft of the nates; (2.) from one patient to another, as
gonorrhceal discharge from the urethra acting on the conjunctiva; (3.)
from the lower animals to man, as in the case of the vaccine virus.
10. Retention of the ordinary secretion of an organ, tends to inflamma-
tion ; retention of urine may be followed by cystitis; distention of the
lachrymal sac, by fistula lachrymalis. Secretion, when healthy, is no
stimulus to the part; but, changed in quantity, quality, or in both, it
may become so.
Inflammation may occur without any apparent or assignable exciting
cause. It is then said to be spontaneous or idiopathic.
J&mulivn-and CfWMtp' of' l7M-Inflammatovy Provess.
Generally speaking, rapidity of progress and intensity of action are
phrases nearly synonymous. Sometimes the process is very gradual in
its advancement; requiring, as in the example of the vaccine pustule,
formerly adduced, eight or nine days for its completion; and many
actions are yet more protracted. After a wound, or other mechanical
injury, the process is usually complete, and suppuration established, by
the second or third day. One day, or less, suffices for the occurrence of
Suppuration in many cases of phlegmonous erysipelas. And the secon-
dary abscesses attendant on phlebitis, there is every reason to believe,
are begun and completed within a very few hours.
Progress varies, as to time and character, according to, 1. the struc-
ture of the part affected. The more highly organized, vascular, and
endoived with nervous energy, the more rapid and sthenic the action—
caeteris paribus. 2. Situation of the part. The nearer to the centre of
circulation, the more disposed to rapidity and extent of action. 3. State
of the part. When vital power has been impaired, by previous inflam-
mation or other debilitating cause, the part is prone to assume morbid
action, and this invariably tends to a speedy and unfavourable issue.
ON INFLAMMATION.
77
All adventitious structures, also, being of low organism and vitally
weak, soon yield before inflammation. 4. Temperament of the patient.
The sanguine favours both rapidity and intensity; in the nervous, action
is readily induced, but is prone to assume the asthenic and chrome form ;
the phlegmatic is unfavourable to occurrence, rapidity, and intensity.
5. Diathesis plainly modifies action both in its occurrence and charac-
ter ; as is exemplified in the scrofulous and rheumatic inflammations.
6. Age. In childhood and infancy, vascular action is both likely and
acute ; often its progress is fatally rapid. In adolescence, its general
character is also acute, easily induced, but not apt to tend disastrously,
there being usually enough of vital power to maintain control; then too,
by reason of habitual activity in the nutritive function, action is usually
attended by copious exudation of the more solid kind, either fibrinous
or albuminous, (plasma or tubercle,) according to the power and dis-
position of the system. In adult life, action is probably less easily
induced, but is actually acute and sthenic. Old Lage is more prone to
passive congestion; Avhen the inflammatory process does occur, it is
generally languid, slow, and tends to an unfavourable result; for both
part and system are lowered in vital power. 7. As regards Sex;
females are constitutionally prone to inflammations; but males are
more exposed to casual predisposing and exciting causes ; the latter
sex too, may be considered as pre-eminently liable to action of an
acute and sthenic type. 8. Habits of intemperance predispose to
inflammation, rapid, intense, and. apt to end injuriously. Sedentary
habits are also favourable to accession, but usually the action is more
under control. Privation—involuntary or assumed—is unfavourable to
accession ; and action is usually chronic and asthenic. 9. Atmosphew
and Season are related to inflammation, not only as important predis-
posing causes, but also as materially influencing its progress and type.
An evil atmosphere impairs the vital power, and so favours the onward
progress of morbid action to a rapid and unfavourable issue. In like
manner, an unhealthy season fully vindicates its title to the name by its
subtle and sinister influence on inflammatory as well as on other forms
of disease, as the history of erysipelas, especially when epidemic,
abundantly testifies.
RESULTS OF THE INFLAMMATORY PROCESS.
I.—Resolution.
This is the most favourable result, and that to which treatment is
usually directed. But, let it never be forgotten, that such treatment
must be early, as well as suitable and active; inasmuch as this result
can only be hoped for Avhile the action is yet beneath the inflammatory
acme. That reached, true resolution—that is, restoration of the part as
regards both structure and function, to its original and normal state—is
The accompanying diagram, though both rude and fanciful, may
78
PRINCIPLES OF SURGERY.
assist to make this more plain. It will also illustrate the opinion held
as to the gradual formation of the true inflammatory crisis.*
Health
The commencement, not inconsistent with healthy structure and
function; its consequences usually salutary; but sometimes, by per-
sistence, injurious. The second stage, a departure from true health,
and pressing on to true disease ; the consequences sometimes salutary,
in local emergencies ; but in general prone to evil by alteration of both
structure and function. The third stage essentially morbid utterly at
variance with healthy structure and function. The higher results,
which follow on the crisis by continuance of the action, are invariably
subversive of function, and destructive of texture ; and, consequently,
pernicious, unless Avhen it has become essential for the Avell-being of
the whole that the part so affected shall be removed.
Resolution may be gradual or sudden, spontaneous or artificial, im-
perfect or complete; the more early and slight the action, the more
likely is the resolution to be rapid, spontaneous and perfect.
When sudden, the term Delitescence is commonly employed ; denoting
a circumstance favourable in itself, but invariably coupled, in the mind
of the experienced practitioner, with a suspicious prognosis. Were the
delitescence simply effected, and there an end, the immediate benefit
derived would be unmixed. But experience tells us, that the abrupt
and sudden disappearance of advancing vascular action in one part, is
often, if not usually, followed by the appearance of similar disorder
elsewhere. And as we have no guarantee that the change shall be to
an equally harmless locality, such change must at all times be a matter
of suspicion, and generally of danger. Inflammation, for example,
may leave one part of the skin, and suddenly re-appear in another por-
tion of the same tissue. Or the action may quit an internal part and
show on the surface. In the one case, probably no harm is done * in
* The dotted lines denote the process of resolution, or the return to health—a sud-
den and direct resolution, or delitescence, b, b, b, lines of gradual resolution'from
ranous points of the ascending action.
ON INFLAMMATION.
79
the other, a decided advantage accrues from the change. But, on the
other hand, delitescence of an erysipelas is often followed by establish-
ment of the inflammatory process in a serous or mucous membrane, or
even in the substance of an important internal organ ; and such change
may be—has been—fatal. The process effecting subsidence of the
original action, and establishment of the new, is termed Metastasis.
Metastasis may be only apparently. Often disappearance of an
external inflammation is quickly succeeded by supervention of an in-
ternal ; and the latter is rightly held related to the former, as effect to
cause. Yet not unfrequently Ave may have the two circumstances con-
temporaneous or nearly so, with their relation reversed; the internal
disorder proving the cause of the subsidence of the external—the less
merged in the greater malady.
Resolution being about to occur, increased effusion probably takes
place ; of serum, liquor sanguinis, or both; by this means, amongst
others, the burdened vessels are more or less relieved; they recover
their wonted tone and calibre; and circulation revives from the im-
pending or actual remora. The red corpuscles resume their individual
distinctness, and the agglomerate masses of both red and colourless
corpuscles first oscillate, and then move steadily on. Sometimes, how-
ever, the colourless corpuscles remain adherent in unusual numbers to
the walls of the vessel; for a time, at least, diminishing the stream.
The local determination of blood ceases ; and the inflammatory changes
begun in that fluid are recovered from. Absorption, which had been
embarrassed hitherto, or altogether held in abeyance, comes actively
into play ; and the effused liquids are more or less rapidly removed—
the more rapidly, the more serous their character. Ultimately an equal-
ity of action is arrived at between effusing blood-vessels and removing
absorbents ; the balance of healthy nutrition in the part is restored ;
and normal function is resumed.
Such change is marked by a corresponding alteration, equally favour-
able, in the local symptoms. The pain and heat are the first to subside ;
then the redness; ultimately the swelling, more or less gradually, dis-
appears. Should the constitution have begun to sympathize, the fever
will be found to decline, as formerly described.
When the inflammatory process has been slow in its advance to the
resolving point, as well as in its subsequent declension, resolution will
probably be imperfect; for thus time has been afforded for the fibrinous
deposit to assume a solid and organized form, less amenable to absorp-
tion than when of the fluid or semifluid consistence which obtains
Shortly after exudation. There is an obvious risk consequently of a
certain change of structure either proving altogether permanent, or
lono- resisting the efforts of the absorbents.
Should the true inflammatory crisis have been closely approached, a
certain loss of vital power will be permanent in the part, even after
change of structure has been apparently altogether recovered from.
80
PRINCIPLES OF SURGERY.
II.—Excessive Deposit, by Exudation through the Vascular Coats
yet entire.
This attends on the advance of the process, and also persists, though
to a diminished extent, during part of its decline. It may be serous,
fibrinous, or both.
1. Of serum, containing more albumen, and of higher specific gravity
than in health.—This, in combination with other effusion, attends on
the Avhole range of the inflammatory process; and is usually situated
circumferentially. Occurring singly, it is the product of a low degree
of action; and, as already stated, may be considered appropriate to
the first stage of the process.
(a.) It may be effused in the interior of the part; occupying the
fibro-cellular tissue, and constituting Acute (Edema. The attendant
symptoms are pain, heat, and redness, proportioned to the amount of
action ; the swelling varies according to the extent of effusion, and nature
of the recipient part; if the latter be unyielding, tension ensues, with
increase of pain and acceleration of the action onwards ; but usually
the surrounding textures are accommodating, the swelling is found soft
when compared with that of fibrinous character, and^ yielding before
the finger by temporary displacement of the serum, is said to pit on
pressure. The pitting, however, is much less distinct in the Acute
than in the Chronic (Edema, to be afterwards described.
(ft.) The serous effusion may be from the surface of the part; whence
it flows harmlessly away, as does the ordinary secretion in health—as
in the case of inflaming mucous membrane. Or it accumulates within
an internal cavity, as those of the serous membranes ; then constituting
Acute Dropsy of the part; the bulk, uneasiness, and disturbance to
healthy function by pressure, varying according to the extent and
rapidity of effusion.
Acute effusion of serum, whether in the form of oedema or dropsy,
usually disappears soon after decline of the action which produced it,
by the resumed and increased play of the absorbents. Herein, again,
practically most different from the result of Chronic Congestion.
2. Of Plastic Fibrin.—This may be exuded by itself, separate from
the serum ; but more commonly with the serum, in the form of liquor
sanguinis, or coagulating lymph ; the latter term denoting its peculiar
property of assuming the solid form by coagulation, when extra-vascu-
lar.- It is the result of a higher degree of action than the purely serous
effusion; and, as formerly stated, may be regarded as the characteristic
product of the second stage of the inflammatory process, Active Con-
gestion.
(a.) It may take place on the surface of the part; as on a serous
membrane, or on the margins of a wound. On coagulation, the serous
portion trickles away ; the fibrinous remaining, in the form either of a
continuous film, or of masses more or less detached ; at first transparent,
afterwards becoming yellowish, and someAvhat opaque. Should the
action now subside, the absorbents find the effusion quite amenable to
their renewed play ; and they remove it. But if the action persist, and
ON INFLAMMATION.
81
yet not have reached the inflammatory crisis, absorption does not take
place, and an opportunity is given for organization of the deposit.
The fibrinous mass or layer separates to form the rudiments of organic
structure, viz. fibrils and exudation corpuscles ; according to the general
law to Avhich such fibrin is obedient, that, Avhen effused from, and
remaining in contact Avith a living texture not truly inflamed, it has a
strong tendency toivards self-organization, assuming the simple struc-
ture of fibro-cellular tissue. It is consequently termed plastic, or
euplastic, according to the facility and efficiency Avith which such struc-
ture is assumed. The fibrils, sometimes parallel, usually cross each
other in various directions, forming an interlacement, in the meshes of
which are the corpuscles. These latter are at first an aggregation of
granules and molecules, in detached forms, termed " exudation corpus-
cles ;" subsequently they change into the form of the rudimcntal cell,
with central nucleus. Perhaps the actionnoAV subsides; and still the
effusion is liable to be absorbed; but it is probable that, previous to
absorption, and auxiliary to that process, the organic formation is un-
done, and the fibrin reduced to a fluid or semifluid consistence, as in
the ordinary absorption of decayed original texture.
Failing absorption, and the action proving still short of True Inflam-
mation, the organic arrangement remains, the basis of a neAV iexture.
But, in order to insure permanence and perfection of structure, it is
expedient that it be supplied Avith blood and blood-vessels. Accord-
ingly the process of Vascularization is commenced. Blood corpuscles
are seen coursing each other through the plasma, in new blood-vessels,
coming from, and again returning by, the vessels of the adjacent original
structure. According to some, these new vessels are, as it Avere, self-
formed in the plasma. Nucleated cells arrange themselves linearly,
elongate, and communicate Avith each other by decadence of the op-
posing surfaces; and the central nuclei first oscillate in the channel or
tube thus formed, and then, receiving an undeniable impetus a tergo,
by the heart's action, communicated through the neighbouring original
vessels, they push onwards, and enter the general circulation, their
place being supplied by blood corpuscles escaped from adjacent capil-
laries. Thus a canal is formed, continuous Avith original blood-vessels
on cither aspect, and circulation established Avithin it. Or, according
to other physiologists, blood corpuscles escape, few in number, from
the adjacent original vessels—oscillate in the plasma—then push across
and join the return veins ; and a new canal having been thus opened
up, these first, or " pioneer" corpuscles arc succeeded by others in a
continuous stream, insuring the patency of the canal, and establishing
its circulation. And from such parent canal, or canals, divaricating
tubes of a similar kind are channeled out by a similar process. Both
theories may be true; neAV vessels may be formed, noAV in the one Avay,
now in the other. To the practical surgeon, the question is of com-
paratively little moment. In whichever way formed, the ncwcapilla-
ries are at first anormally capacious, larger than the vessels which sup-
ply them ; " they are afterwards contracted by the formation of a base-
ment membrane lined Avith epithelium."
Thus far advanced—endued with an organic arrangement, and sup-
82
PRINCIPLES OF SURGERY.
plied with blood-vessels, in which blood is actively circulating—the
plasma is noAV capable of assuming a higher degree of organization,
and in due time comes to resemble the original texture (with some
exceptions,") from which it Avas effused—a process of change mainly
attributable to transformation of the nucleated cells. Be it remembered,
however, that this process is incompatible with the co-existence of true
inflammation, according to our acceptation of that term. Wherever
this occurs, the fibrin is aplastic ^ it never reaches higher in the range
of organization than the exudation corpuscle ; thence degenerating into
the pus globule, it is associated with the serum of the liquor sanguinis,
from Avhich it had just separated, to constitute purulent matter. And
such degeneration will be continued so long as true inflammation
persists. It is only after subsidence from the inflammatory acme, that
some of the fibrin becomes organized—as in the case of granulation—a
portion only, instead of all, being then throAvn waste in the shape of
pus.* True inflammation, hoAvever, may be, and usually is, surrounded
by a less degree of action, giving rise to plastic fibrinous effusion ; and
hence we find, as formerly stated, the purulent formation usually encir-
cled, and happily limited, by a barrier of fibrin more or less advanced
in organization. But should the action disregard that barrier, establish-
ing itself where active congestion only had hitherto been, the fibrin
ceases to be plastic: and, besides, that Avhich had been previously
effused, to construct the barrier, has its advancing organization not only
arrested, but broken up and undone.
Fibrin, more or less plastic, effused on the free surface of a mem-
brane, is usually termed false membrane, assuming a structural arrange-
ment, in the first instance, resembling that of the buffy coat of the blood,
and forming a layer or coating someAvhat similar to the original and
invested tissue ; when accompanied by purulent or sero-purulent secre-
tion, as it too frequently is—an indication of true inflammation; but
when either alone, or attended by effusion simply serous—showing the
presence of an amount of action short of that which is truly inflamma-
tory. When of truly inflammatory connexion, as indicated by the co-
existence of purulent or sero-purulent effusion, it is usually of low
organism ; and to be regarded as analogous, not to the simple adhesion
of a Avound, but to the partially organized fibrinous exudation Avhich
precedes and limits the purulent secretion in an ordinary abscess.
(£>.) Fibrin maybe exuded in the interior of the part; and being at
first fluid, insinuates itself to fill up every minute space, occasioning
enlargement; cohesion is generally impaired. If the action be acute,
the part is softened as Avell as swoln, a considerable proportion of
serum being mingled with the fibrin ; and on the exterior of the fibrin-
ous range, is found a more extensive one of serum alone. If the action
be sIoav and gradual, induration is found instead of softening ; the
serum having been absorbed, besides in all probability having been
* The opinion that a minor degree of action is most favorable to organization and
vascularization, and more especially to vascularization, is strikingly corroborated bv
an excellent paper by Mr. J. Dalrymple-" On Rapid Organization of Lymph in
Cachexia. —Medico- Chir. Trans. J r
ON INFLAMMATION.
83
sparingly effused at first; the fibrin also has had full time to assume
the solid form, and is more or less advanced in organization.
If the action continue, in a chronic and subdued form, the deposit
becomes fully organized and Arascular ; and being noAV little amenable
to absorption, a serious change, more or less permanent, is thus effected
in the structure of the part; it is indurated, thickened, and enlarged.
And should such action persist, causing continuance of plastic deposit
in greater abundance than absorption can normally control, the enlarge-
ment and change of structure gradually increase, giving rise to the
simplest form of tumour. The action ceasing, so does redundancy of
deposit; the absorbents then busy themselves in attempts to clear a\vay
what has been already heaped up, and in this good work they may
often be materially assisted from Avithout by the hand of the prac-
titioner.
(c.) The effusion may be both on the surface and in the interior ; for
instance, into the texture and on the exterior of a serous membrane ;
or on the surface of such a membrane, and into the parenchyma which
it invests. The result is a combination of the changes described in
the tAvo preceding sections of this subject.
Thus Ave see that fibrin, effused during the inflammatory process,
undergoes various changes, according to the grade of action .by Avhich
it is accompanied. It maybe absorbed; resolution. Or it remains
and becomes organized; by persistence of the first stage of action, or
of the second in a subdued form. Or it degenerates to form pus ; the
true inflammatory crisis having been attained.
Inflammation having been reached, organization ceases ; on the sub-
sidence of the action to a minor grade, it may again advance. But to
all fibrin so organized, a general rule seems to be applicable, viz., that
it is of low or imperfect organism, and, by consequence, liable to de-
struction in one of two ways; either by simple absorption, on subsi-
dence of all perverted vascular action, or by a secondary accession of
such action advancing to suppuration and ulceration. This is favour-
able ; as regards the discussion or disintegration of simple enlargements
of inflammatory origin. Unfavourable, as regards reparation of solu-
tions of continuity ; and hence it is that the cicatrix by granulation—a
process ahvays preceded by true inflammation—is often undone, and
the Avound made gaping as before, while union by adhesion or by the
slow " modelling process," into Avhose composition true inflammation
does not and cannot enter, remains firm and enduring.
It is only, then, the non-inflammatory exudation of fibrin which is
thoroughly euplastic. By it Avounds unite, bones knit, and arteries are
consolidated. These salutary processes are wholly incompatible with
true inflammation ; and often are but ill-performed after its subsidence.
Inflammation is essential—or indeed useful—toAvards reparation,
only Avhen the liquor sanguinis, by reason of debility in the part, is
deficient in fibrin; as in an old and indolent ulcer. An invariable
effect of the inflammatory process, we know to be a marked augmenta-
tion of that plastic substance. It will bring an additional and probably
sufficient amount of reparative material to the part, therein before^ de-
fective ; but such fibrin is not capable of due reparative application,
84
PRINCIPLES OF SURGERY.
until the action Avhich brought it has subsided from the true inflamma-
tory crisis. Even then, as just stated, organization proceeds at a dis-
advantage ; but organizable fibrin of the second class—that Avhich ia
unconnected Avith true inflammation being of the first—is better than
none at all.
The inflammatory process increases the facility and rapidity with
which fibrin assumes an organic arrangement; "but the arrangement
assumed is apt to be imperfect and of low type, Avhen contrasted with
that which is thoroughly of non-inflammatory connexion.
III.—Inflammatory Hemorrhage and Extravasation.
When the process has approached the true inflammatory crisis, we
have seen that the altered vascular coats are apt to give way, permit-
ting the contained blood—liquor sanguinis and red corpuscles, in mass—
to escape more Or less copicudy. If this occur on the surface, the
accident is termed Hemorrhage ; if in the interior, Extravasation. The
former most frequently takes place in inflaming mucous membrane, the
blood escaping by the mucous outlet; and is not to be rashly checked,
inasmuch as it generally tends towards a beneficial result. The impli-
cated vessels are not only relieved of part—it may be the greater part—
of their burden ; but a general resolutory effect may be obtained, as if
the flow Avere an artificial one from a vein at the bend of the arm. In
such cases, a practitioner suddenly called must take care not to sup-
pose that to be of itself a disease, requiring immediate arrest, which ia
actually a means of cure directed against advancing inflammation—
requiring to be watched, perhaps favoured, but only to be arrested
when threatening to prove excessive.
When, however, the hemorrhage takes place into an internal cavity,
it cannot be too soon arrested, and Ave would rather prevent it alto-
gether if possible ; seeing that its presence, bulk, and pressure, may
excite action of a still higher grade, or seriously interfere with the func-
tion of neighbouring viscera. In the chambers of the eye, for instance,
extravasation may hurry on action to ultimate disorganization of the
eyeball; in the cavity of the peritoneum, peritonitis may be hopelessly
aggravated ; in the pericardium, the heart's action may be fatally over-
borne ; in the membranes of the brain, coma by compression is es-
tablished .
Ex'ravasation is seldom but injurious, and therefore at all times to
be avoided. Occurring in an internal organ, it occasions serious con-
sequences, not only by arrest or impairment of function in that part
itself, but also, perhaps, in others adjoining, by pressure made on them.
Occurring externally, it is unfavourable, as indicating a high grade
of action, breaking up texture, and paving the way for suppuration.
IV.—Suppuration.
True inflammation is essential to the first formation of pus • but
once formed, a less amount of action is sufficient to maintain the secre-
ON INFLAMMATION.
85
tion. It has been objected that purulent collections are formed in the
latter stage of phlebitis, too rapidly to admit of precedent inflammation ;
such occurrences, hoAvever, will be aftenvards shown to be no excep-
tion, but corroborant of the general laAv here laid down.
Suppuration, originated by true inflammation, and maintained by a
minor grade of action, will probably be arrested for a time by re-induc-
tion of the true inflammatory crisis; according to the general law,
whereby such action arrests secretion in general. For example, during
the early stage of gonorrhoea, profuse purulent discharge having just
set in, a strong stimulant injection may be employed, giving much
pain; the part dries up; only, however, again to break out with
increased intensity, so soon as the second acme of inflammation has
begun to give Avay; in fact, this may be said to partially resolve itself
by a renewed and increased effusion.
Pus may be regarded as a changed condition of the liquor sanguinis,
consisting of globules, and small molecular particles, more or less
numerous, contained in a thin serum. The serum is analogous to that
of liquor sanguinis, the globules and molecules to its fibrin; indeed,
there is every reason to believe that the globules are actually fibrin in
a degenerated form. The formation may be either intravascular or
extravascular—that is, pus may be formed more or less perfectly within
the vessel, and separated from it as a secretion, as Ave observe in
inflamed mucous membrane, and in the granulative structure ; or the
purulent change may be entirely subsequent to effusion. In the latter
case, the process Avould seem to be as follows :—Liquor sanguinis is
effused ; it separates into serum and fibrin ; the latter, coagulating,
assumes the solid form, at first uniform and unbroken, then in granules ;
granules change into exudation corpuscles, approaching the cellular
form, but instead of attaining to the organized condition of true nucle-
ated cells, they degenerate and become the pus globules and mole-
cules ; these mingle Avith the serum from which they had so recently
separated, and imparting to that fluid a Avhitish colour and opaque
consistence, constitute pus. This resembles cream in consistence and
appearance ; opaque ; yellowish-white or greenish, insoluble in water,
but readily mixing Avith it; heavier than that fluid, the specific gravity
varying from 1030 to 1040 ; coagulable by muriate of ammonia; not
prone to putrescence ; of a " sweetish and mawkish taste ;" emitting
scarcely any peculiarity of odour Avhen newly and simply formed, but
contaminating the air much and noisomely Avhen either connected Avith
carious or dead bone, or allowed to accumulate and remain in quantity.
It is not a corrosive liquid, as the ancients imagined, but bland and
protective ; tender granulations, for instance, are invested Avith it, for
the express purpose of protection, and that effectually, until covered in
by cuticular formation. It is true, that Avhen " cribbed, cabin'd, and
confined," in the interior of a part, it induces disintegration of those
textures with Avhich it is brought immediately in contact, not, hoAvever,
by erosion, but by the pressure of its accumulation ; such pressure in-
ducing absorption, ulceration, or both.
Nor is its formation a chemical process, as at one time imagined—a
melting down of the solids, by putrescence, as the name of pus (nvu)
8
86
PRINCIPLES OF SURGERY.
implies. It is essentially a vital action, quite as much as the secretion of
an ordinary fluid, say the serous or mucous ; only the one is the product
of healthy, the other of morbid vascular action. As the inflammatory
process approaches the completion of its third stage, we saAV that there
Avas increased and almost complete remora of the blood, copioua
fibrinous effusion, extravasation of blood by giving Avay of the altered
vascular coats, with consequent breaking up of normal texture ; and
that in the part so affected the formation of pus then speedily occurred,
the pus occupying the place of the disintegrated original texture. It is
a perversion of the liquor sanguinis, partly intravascular and partly
subsequent to effusion. When elaborated within the vessel, it may be
more or less copiously effused therefrom, as ordinary liquor sanguinis
would. In the latter case, as already stated, it is belieAred to consist of
the folloAving successive changes; 1. liquor sanguinis effused in a part,
the seat of the true inflammatory crisis ; 2. its coagulation or separation
into serum and fibrin ; 3. the granules of the latter form exudation cor-
pucles; 4. these degenerate into pus globules, Avhich, along with
small molecular particles, furnished from the granules, mingle with the
serum, and form pus. To the completion of such change, the contract
of atmospheric influence is decidely favourable. On subsidence of the
action from its acme, the Avhole of the effused fibrin does not thus de-
generate ; the amount of action is no longer incompatible with the plastic
function ; part of the fibrin remains adherent to the original tissue, and
gradually becomes organized ; and thence and thus are constituted the
granulations of an open suppurating surface, and the limiting cyst of an
internal abscess.
The essential point in the formation of pus, then, is the presence of
actual and true inflammation ; and the peculiarity of its constitution is
the presence of the globules and molecules. These molecules arc
small rounded particles of fibrin, some floating loose in the serum,
others contained Avithin the globules. These latter are thin cells, con-
taining fluid and a greater or less number of molecules, and sometimea
with granules of fibrin attached to the exterior. They are rougher on
the surface and more truly globular than the blood disc; the greater
number are also larger than the blood disc, and altogether they are
more varied in size, the average diameter probably ^05 of an inch.
They have little power of cohesion among themselves, and "in pro-
portion as they predominate they impair the consistence of fibrin or
mucus Avith which they are combined." Probably it is to the infiltra-
tion of pus that the inflammatory softening of texture—termed, in regard
to the nervous tissue, ramollissement—is attributable.
Pus, as Ave have described it—the result of vital action—is of normal
character, and usually termed healthy, or laudable. But various cir-
cumstances may cause deviation from this. A chemical action may be
superadded to the vital; probably the agency of atmospheric contact,
producing hydrosulphate of ammonia by decomposition of the albumen
of the serum, whose presence is indicated by offensive odour and by
the blackening of silver probes brought in contact with the fluid. Pu-
trescence may be thus begun in the fluid ivhile it is yet in contact with
the living part, Disintegration of the surrounding texture, by ulcera-
ON INFLAMMATION.
87
tion, is often co-existent with the formation of pus ; it will then be
mingled Avith the fluid debris of the part, and consequently more prone
to chemical change. Or it may be mixed with blood, either fluid or
solid, reddened thereby, and found to contain blood discs or masses of
coagula; and, accordingly, termed sanious or grumous. In those of
weak systems, it is often deficient in solid matter, consisting chiefly of
a thin serum; it is then termed serous. In the scrofulous, it is often
not only serous, but mingled Avith flakes or masses of broken down
tubercle, giving more or less of a curdy appearance ; to such the terra
scrofulous is usually applied. Sometimes it is impregnated with a sub-
tle virus, as the venereal or vaccine; it is then said to be specific.
Further, it may be variously mixed with secretions from mucous and
serous membranes, and termed in consequence sero-purulent and muco-
purulent.
Coagulated blood, undergoing a peculiar process of decomposition,
becomes liquid, and this fluid closely resembles pus in appearance ; but
the researches of Mr. Gulliver have clearly shown that it is not true
pus, only its counterfeit.
Pus may be formed on the free surface of a part, and be thence dis-
charged ; or in the interior of a part, and lodge there. In the latter
case, the immediate effect of suppuration varies according to the nature
of the part. If loose and extensile, as is ordinary cellular tissue, often
the pain and throbbing cease, or, at all events, diminish, and the swell-
ing becomes paler, soft, and fluctuating; if, on the contrary, the texture
be dense and unyielding, as the osseous and fibrous, the general inflam-
matory action, Avith its indications of tension, redness, heat, and pain,
is much aggravated. The result also depends on the form of action
which has preceded. If it have leisurely advanced through its suc-
cessive stages, the pus is not secreted ere a barrier of plastic fibrin has
been formed, to limit it, and protect the surrounding parts, as in the
ordinary abscess. But if a rapid transition have been made from the
origin to the acme, no fibrin is interposed—either it is not exuded, or,
rather, the exudation is Avholly aplastic—the pus is infiltrated diffusedly
into the neighbouring tissue, breaking it up, and causing its destruction
by ulceration and gangrene, as in phlegmonous erysipelas.
We have just seen, that on the occurrence of suppuration the symp-
toms of the local inflammation sometimes subside, sometimes become
aggravated. A change also usually takes place in those of the general
inflammation, or inflammatory fever. It was ushered in hj a rigor;
and the same phenomenon usually indicates the approaching change.
The inflammation continuing, the fever may continue also ; it may in-
crease with the inflammation's increase, or subside with its decay.
Usually the rigor is folloived by a marked remission of all the febrile
symptoms ; and this remission either cominues until resolution is com-
plete, or is superseded by the accession of febrile action of another
type, termed Hectic. And this latter is sure to occur, when the suppu-
ration is profuse and long continued, Avhen the patient is of an already
debilitated frame, or Avhen it occurs in an internal organ important in
the animal economy.
This fever is a form of Constitutional Irritation, widely different from
88
PRINCIPLES OF SURGERY.
the inflammatory type ; and may be produced by other circumstances
besides mere suppuration. Its general character is decidedly remittent,
more especially when contrasted in this respect with the precedent
inflammatory fever. Its ordinary symptoms are, a general paleness of
the surface, excepting the cheeks, on which there is usually a delicate
and circumscribed bloom ; beautiful, yet a strikingly morbid indication
—" like the unnatural red which autumn paints upon the perish'd leaf."
The appetite is resumed, and sometimes apparently digestion also; the
former is sometimes inordinate ; but yet emaciation sets in and advances,
sometimes Avith great rapidity. The tongue is preternaturally clean,
especially at the tip and edges ; at first moist, but ultimately becoming
dry and glazed, and perhaps studded Avith aphthae. The condition of
the bowels varies, but constipation usually predominates, until the
fever's extreme has been attained, Avhen obstinate diarrhoea, termed
colliquative, is established. There is thirst; and burning heat is much
complained of in the cheeks, soles of the feet, and palms of the hands;
the general skin, at the commencement, is both dry and Avarm, but soon
shoAvs a tendency to profuse perspiration, totally ineffectual however in
resolving the disease. Respiration is rapid and short, and readily
accelerated. The pulse is frequent, small, and sometimes hard; and
also, easily affected by exertion or emotion. At tAvo periods of the day,
noon and evening, there is an exacerbation of all the febrile symptoma,
preceded by chill, and followed by perspiration. Perspiration is most
profuse tOAvards morning, and may then be regarded as a resolution of
the evening's exacerbation. The urine varies ; sometimes scanty and
high coloured, more frequently copious and pale. The eyes, though
sunk in hollow orbits, are usually bright and intelligent. The lower
extremities become swollen by oedema. " The sleep is disturbed and
unrefreshing ; and there is a continual feeling of lassitude and debility;
but with all this failing of the physical powers, the mind remains cheer-
ful and unclouded to the last, and seems to gather fresh hope from the
very causes of despair."*
Such is the fever, strongly marked, and advancing to a fatal termina-
tion ; but of course it is found to vary in duration, intensity, and issue,
according to the nature and duration of the cause Avhich called it forth.
On removal of the cause, recovery is often extremely rapid.
Many imagine that the accession of hectic fever is attributable to the
admixture of pus in the circulation. But it seems more reasonable to
assign as its cause a very opposite circumstance, namely, the constant
* I cannot resist appending a beautiful description of some of the more striking fea-
tures of this disease, from the non-professional pen of a most close and skilful observ-
er of Nature—in all her varied phases and forms :—" But there were times—and of-
ten too—when the sunken eye was too bright, the hollow cheek too flushed, the
breath too thick and heavy in its course, the frame too feeble and exhausted, to escape
their regard and notice. There is a dread disease which so prepares its victim, as it
were, for death ; which so refines it of its grosser aspect, and throws around familiar
looks unearthly indications of the coming change—a dread disease, in which the
struggle between soul and body is so gradual, quiet, and solemn, and the result so
sure, that day by day, and grain by grain, the mortal part wastes and withers away,
so that the spirit grows light, and sanguine with its lightening load; and feelin«im-
mortality at hand, deems it but a new term of mortal life—a disease in which d"eath
and life are so strangely blended, th it death takes the glow and hue of life and Ufa
the gaunt and grisly form of death."
ON INFLAMMATION.
89
draining away of that portion of the blood, its liquor sanguinis, Avhich
is peculiarly available for the purpose of nutrition. Pus we have seen
to be a perversion of that portion of the blood ; and the habitual loss of
it seems much calculated to impoverish and weaken the frame, inducing
febrile disturbance of healthy function, with debility as a prominent
characteristic of such disorder. Pus, directly mixed with the circula-
tion—if not speedily extruded by elimination—produces a much more
grave disturbance of the system, as will afterwards be considered.
During a profuse suppuration, it is not unlikely that a portion may be
taken back again into the system, yet it is not a fluid easily absorbed,
inasmuch as its solid particles are of large dimensions, and not fitted for
passing through unbroken membranous coats; its serosity may pass
readily, but the globules, Avhen absorbed, must surely undergo some
previous modification.* And so, if we are to suppose that the blood is
contaminated by pus in hectic, there is every reason to believe that
it is by absorption of it, and not by its direct intermixture ; and also
that the pus, when intra-vascular, is a modified form of that fluid. Yet
such modified and indirect admixture of pus cannot be essential to the
production of hectic, seeing that that form of disease occurs without
any apparent purulent formation ; for instance, as a consequence of
hopeless organic disease in some internal part, of Avhose condition sup-
puration is not and has never been an element.
When pus is formed rapidly after the onset of inflammation, and dif-
fused into the surrounding textures, from ivant of antecedent protective
exudation of fibrin, the injury, as already stated, is great; by infiltration,
disintegration, and gangrene. "The constitutional symptoms attendant
thereon, are notjthose of hectic, but of Irritative Fever ; a condition, as
it Avere, immediate between the hectic and inflammatory, combining
some of the characters of each. In the part, the advancing destruction
of texture is preceded by spreading inflammation of a rapid and intense
kind ; the action tends to rouse the system, while its result on texture
has the directly contrary effect. Such being the compound nature of
the local mischief, it need not surprise us to find the general disorder,
to which it gives rise, consisting of febrile excitement, modified and
overborne by depression of the vital powers. The pulse is frequent and
hard ; at first with indication of strength but soon betokening manifest
debility. The tongue is usually tremulous, and covered Avith a thick,
dark-coloured, offensive fur ; moisture gradually leaves it, and it ulti-
mately becomes hard, brown, and dry. The urine is scanty, high-
coloured, and of unpleasant odour ; sometimes apparently suppressed.
Sometimes there is diarrhoea, sometimes constipation. Rigors are fre-
quent, followed by perspiration, usually profuse. There is much rest-
lessness, with agitation of manner, anxiety of expression, and pinching
* This statement may seem at variance with the previously asserted formation of
pus within the vessels, and elimination therefrom, as in ordinary secretion ; yet the
two circumstances are quite compatible, for there is good reason to suppose that the
pus globules, when first formed, are comparatively minute, consisting of the mole-
cules enveloped in a cell or cyst; and that, in the case of their intra-vascular forma-
tion, it is after their transudation that they enlarge to their ordinary dimensions, re-
ceiving their fluid contents by endosmosis.
8*
90 PRINCIPLES OF SURGERY.
of the features. Respiration is hurried and sighing, and there is a
sensation of oppression at the chest. The mind is either greatly de-
pressed, or excited by occasional delirium. The strength is much
prostrated; hiccup sets in ; and fatal collapse is imminent.
V.— Ulceration.
Until lately, the Hunterian theory was generally received, that ulce«
ration, or the process whereby a breach of continuity is effected in a
living solid, by the action of the part itself, Avas the exclusive work of
the absorbents. Without denying that absorption, by both lymphatics
and veins, goes on to some extent during ulceration, and that a part of
the destructive process may be so produced—yet, there is every reason
to believe that the major and more important part is effected indepen-
dently of that class of vessels ; and that ulceration is a product of true
inflammation, consisting of, first, a vital softening of the changed and
suppurated texture, which then undergoes molecular disintegration, and,
reduced more or less to an apparently fluid form, passes away along
with the purulent discharge. If by any means prevented from escaping,
some of the fluid debris may be taken back by absorption into the sys-
tem ; ordinarily, however, it is washed away as both noxious and effete.
And should it be otherwise, it must be remembered that such absorp-
tion of debris from the part, after it has assumed the fluid form, is a
very different thing from the action which caused it to become so.
The steps of the process are—1. True inflammation, with suppuration;
2. Softening of the truly inflamed part; 3. Its reduction towards a fluid
form—a vital act—more or less complete ; 4. Disintegration—or death
and detachment—in minute portions, or molecules; 5. Mixture with
the pus, and removal in one common discharge. Pervading this pro-
cess, there is some absorption; but the amount of that action is not
only inadequate to effect the change, but is even below the ordinary
standard of health. It was diminished or almost arrested, during the
persistence of true inflammation ; although resumed, it is yet but feeble,
during the continuance of true inflammation's product—ulceration.
Sometimes there is good reason to believe that the originating inflam-
mation does not subside at all on the occurrence of ulceration but re-
mains unimpaired, so rendering the latter action remarkably acute;
then absorption will continue to be almost wholly in abeyance.
The more important arguments in support of such doctrine are the
following:—1. Ulceration is an immediate result of Inflammation or is
co-existent with it; and during inflammation, absorption in the part
inflamed is very much diminished, if not altogether arrested. Inflam-
mation simply subsiding, or having just touched its true acme w
barely so, is followed almost immediately by very actively renewed
absorption, by which the inflammatory effusions are speedily cleared
away; but when the action does not so subside, and advances to suppura-
tion with ulceration, the result is otherwise ; absorption is not renewed
with any energy if at all, until the action has abated. During the per-
sistence of such action, inflammatory effusion may, to a certain extent
disappear; but only by disintegration along with the original tissues'
ON INFLAMMATION.
91
and admixture with the extruded purulent discharge. 2. Certain struc-
tures resist all stimulants to absorption, long and successfully, yet are
remarkably prone to ulceration ; and the inference seems plain that the
two actions,—one opposed, the other embraced, by the same part, and
at the same time,—must be dissimilar. Malignant tumours, for ex-
ample, Avill not diminish in their true structure, far less disappear by
absorption, yet are not only apt to ulcerate spontaneously, but certain
to ulcerate when unwisely and rudely stimulated, as by friction or pres-
sure. And certain normal tissues, as cartilage, maybe long and much
compressed, as by aneurism or abscess, without being affected by ab-
sorption ; yet having become vascular, and the seat of perverted vascu-
lar action they ulcerate fast and readily. 3. In the case of virulent
inoculations, Avhence the system is to be contaminated by absorption of
virus from the part inoculated—as, for instance, in the primary venereal
ulcer—it is usually considered that the system is safe during the for-
mation of that ulcer. The part inflames and ulcerates ; in a fe\v days
after the first blush of inflammation, the ulcer is fully established ; and
during these first feAV days, according to the Hunterian theory, there
should have been great and constant activity of the absorbents, pouring
in the virus into the circulation along with the debris of texture; but
the experience of the practitioner tells an opposite tale—hoiv there
seems to be little or no absorption during that period, and that if he
have an opportunity of destroying the part with caustic any time within
that period, the disease is arrested, inasmuch as, up to that time, it has
been entirely local, and not disseminated, by the play of the absorbents,
throughout the system. Ulceration is a rapid process ; and if effected
by absorption, then the action of the absorbents in forming such an
ulcer must have been great, and the system should have been inevitably
involved long before the fourth or fifth day. And yet it is not so. 4.
Ulceration is most rapid when absorption is generally supposed to be
least active ; that is, during the persistence of acute inflammation. 5.
Passive venous congestion in a part is directly opposed to absorption,
yet favours ulceration by proving a strongly predisposing cause to in-
flammation, which, occurring in a part of Ioav vital power, passes on
almost uncontrolled to a high result, namely, disintegration. All new
formations are prone to ulceration in a similar way, being of Ioav organ-
ism and Aveak vital poAver. Granulations, for instance, are so situated.
They are liable to both absorption and ulceration; by the former—a
sIoav, insensible process—the new formation is diminished gradually,
contraction of the surrounding original textures is favoured and en-
hanced, and the extent of cicatrix diminished ; by the latter—preceded
and probably accompanied by inflammation—the cicatrix is undone
rapidly, and the breach made wide and gaping as before. 6. A part
to be absorbed is generally supposed to be previously reduced to a
state more or less fluid. This change is not alleged to be the work of
the absorbents, but is generally admitted to be the result of vascular
action, infiltrating and breaking up tissue by fluid effusion. To consti-
tute ulceration, it only requires the addition of molecular disentegration
or detachment of the parts so changed—by further continuance of the
destructive infiltration—which then inevitably mingle with the purulent
<>2
PRINCIPLES OF SURGERY.
fluid to form one common discharge : and the idea of such addition
seems infinitely more feasible, than to suppose absorption to be sud-
denly and actively resumed for the nonce, during the persistence of an
action avowedly inimical to that function. After the disintegration and
solution, a portion of the debris may be subsequently taken back by
the absorbents: but these vessels are then dealing with the results of
ulceration, not effecting that process. 7. Absorption is proved to be
feeble during acute ulceration ; a strong narcotic, in the fluid form, most
favourable to absorption, may be then applied to the part with com-
parative impunity ; Avhile, subsequently to abatement of the ulcerative
action,-a much less dose Avill produce a much greater effect if brought
hi contact Avith the raw granulating surface.
Sundry objections to this theory will be noticed and explained, in
treating of ulceration occurring in the different tissues.
Ulceration may occur either in an unbroken part, or Avhere there has
been previously a breach of structure. The process is begun by per-
verted vascular action, Avhich sooner or later reaches .its acme, with
suppuration ; it. does not stop there, but advances a step farther ; to
infiltration, softening, and partial breaking up of texture—true inflam-
mation—is added farther softening and molecular disintegration—true
ulceration. If on an open surface, the debris mingles Avith the puru-
lent discharge, and so escapes ; Avhen on a surface previously unbroken,
the discharge accumulates in the form of a pustule or small abscess;
this breaks, its contents are evacuated, and the ulcerating surface is
disclosed beneath. So long as true inflammation continues, ulceration
does not cease ; and the greater the amount of vascular action, and the
less the amount of vital poAver, the more rapid and extensive is the
work of destruction. With ordinary inflammation, and considerable
poAver of control in the part, ulceration advances steadily, presenting
the usual characters of the acute form of that process. With higher
action, destruction is more rapid, very painful, and accompanied by
greater redness, heat, and SAvelling ; such an ulcer is usually said to be
inflamed—all advancing ulcers are inflamed, but this form has inflam-
mation as an unusually prominent characteristic. With still higher
action, or Avith the same combined with less poAver, destruction is more
rapid still, as if the part were consumed by some unseen agent; and
the ulcer is termed Phagedoenic. With action yet increased, and
poAver impaired—one or other, or both—destruction is still more speedy,
but in a different form ; the part no longer dies in molecules, but in
mass ; ulceration is merged in gangrene. On the other hand, inflam-
mation, having once established ulceration, may speedily thereafter
subside ; the latter action, under such circumstances, soon ceases, and
is followed by reparation ; such an ulcer is termed healthy or healing
Or, a subdued vascular action remaining, ulceration advances stealthily
and slowly, and is said to be of the chronic form.
Again, the reparative action may flag and prove imperfect; the sore
is then termed Aveak. Or there may be not only weakness and imper-
fection, but a total want of the reparative action ; the sore is then called
indolent. Or the Avork of reparation is from time to time interrupted
by subacute inflammatory re-accessions, and the nervous function of the
ON INFLAMMATION.
93
part becomes pre-eminently disordered ; such a sore is called irritable.
Or the Avork of destruction has been combined with a tubercular vice
in both the system and the part, and the work of reparation is thereby
rendered feeble and impotent: such a sore is termed scrofulous.
The farther removed the ulcer is from the characters of the healthy
and healing, the less laudable is the purulent discharge. Inflammation
either persisting or advancing, the discharge is thin, acrid, not unfre-
quently bloody, and more or less impregnated with the softened debris.
When, on the contrary, action has not only subsided from the inflam-
matory standard, but is becoming insufficient even for reparation, the
discharge is either simply serous, or composed of this fluid containing
a small amount of fibrin ; Avhich latter substance is neither in solution,
nor in the form of pus globules, but in thin flakes.
By some, it is supposed that ulceration may be occasioned directly
by Passive Venous Congestion—as in the loAver limbs ; and they con-
sequently speak of the Congestive and Inflammatory, as different forms
of ulceration. But it is not so. The congestion is the predisposing
cause, not the immediate ; it favours the occurrence of inflammation;
and this coming, finds the part possessed of but little vital powers—as,
indeed, the existence of such congestion plainly indicates; suppuration
and ulceration are soon reached; not the direct result of congestion,
but of inflammation induced and aggravated thereby.
Certain tissues are more prone to ulceration than others. Skin,
mucous membrane, and cellular tissue, are peculiarly liable to fall
before it; Avhile the vascular, nervous, and fibrous tissues resist it
stoutly. Often advantage is derived from this; sometimes eA'il. The
comparative immunity of the nen^ous and vascular tissues is plainly
beneficial; and, in like manner, it is often fortunate that important parts
are protected by fibrous expansion, Avhich can successfully resist, at
least for a time, the encroachment of suppuration advancing from with-
out. But when the purulent collection is Avithin the fibrous layer, then
mischief is likely to accrue ; inasmuch as the natural tendency of the
pus outwards—by ulceration of intervening texture—is opposed, while
deep and important parts suffer sadly by the delay.
The causes of ulceration are the same as those of inflammation.
These actions are portions of the same general process, Avhich com-
mences Avith simple vascular excitement, and may end in gangrene.
Ulceration is the higher grade—intermediate between suppuration and
gangrene; something more than the former—disintegration and solu-
tion of texture, as well as the formation of pus ; something less than
the latter—the part not dying and being detached at once in a conti-
nuous mass, but slowly and by molecules. Whatever favours the
occurrence and continuance of true inflammation, and Avhatever is un-
favourable to the due maintenance of vital power in the part, Avhereby
inflammation occurring might be resisted or controlled, is a cause of
ulceration.
Inflammation subsiding, so does ulceration; and the action of de-
struction is folloAved by that of reparation—granulation. The succes-
sion may be rapid or slow. On the occurrence of gangrene, the dead
part is separated from the living by ulceration; and in the furrow so
94 PRINCIPLES OF SURGERY.
*
formed, the two actions of destruction and reparation are usually seen
at work together and in harmony. The ulceration has not proceeded
much deeper than true skin, Avhen already in the true skin granula-
tions are being formed, as if Avith the view of at once closing the breach
and atoning for the loss of substance. Whereas Ave find many a breach
of surface in the lower limbs, in which ulceration has for Aveeks ceased,
but in Avhich there may be no effectual reparative effort for many wceka
to come.
Ulceration may be attended by constitutional symptoms. If acute,
inflammation persisting, there may be febrile disturbance of the inflam-
matory type. If chronic and tedious, with a profusion of discharge,
hectic may ensue.
Of course, ulceration is to be considered as altogether different from
loss of substance caused purely by absorption, either interstitial or con-
tinuous—independent of true inflammation, and unaccompanied by
suppuration—a subject to be afterwards considered.
VI.—Mortification.
Mortification, an undoubted termination of inflammation as Avell as of
all other vital change, maybe reached at once, from intensity of action,
deficiency of poiver, or a combination of both; or the intervening stages
of suppuration and ulceration may be either barely touched at, or more
or less dwelt upon. The broken up texture, softened, and infiltrated
by liquor sanguinis, pus, and extravasated blood, has its circulation
wholly arrested ; and it dies, not by particles, sloAvly, and almost imper-
ceptibly, but plainly, at once, and in mass. Vital power has ceased,
chemical change advances unopposed, and the part is decomposed by
putrescence.
Mortification is the general term which includes the whole process
from its commencement to completion. It is subdivided into gangrene
and sphacelus ; the former denoting the process of dying; the latter, the
result of this, or actual death of the part.
Q-angrene being about to occur, the signs of the existing intense in-
flammation become modified. The redness passes into a dark and
livid hue, for circulation has ceased. Circulation having been arrested,
so is effusion, and the swelling grows less tense. All vital action de-
caying, pain and heat remarkably abate, and often cease suddenly.
Sensation grdually leaves the part; just before, it could not be pressed
on, hoAvever slightly, Avithout much aggravation of pain, previously
severe ; now, even rude handling is borne Avith impunity. As the cir-
culation, the source of animal heat, has ceased, temperature necessarily
decreases, and usually Avith rapidity. The part containing much in-
flammatory effusion, chiefly fluid, putrescence is speedy, and increases
both softening and moisture ; and as the result of the chemical change
an offensive odour is more or less freely exhaled. The surface" is
usually studded with phlyctenas ; that is, elevations of the scarf-skin by
putrid serum ; readily distinguished from dark vesicles filled with bloody
serum, which not unfrequently attend on simple bruise, by ob servin"
that the epidermis is not only detached from the cutis at the elevated
OF INFLAMMATION.
95
spot, but all around ; that consequently, the phlyctena may be made to
Blide from place to place, by slight pressure ; and that the phlyctena is
not attended with heat, pain, and swelling, as is the mere vesicle, but
with all other symptoms of advancing gangrene. When this is
limited to the part originally inflamed, the discolouration is circum-
scribed, and may have its border even abrupt; but Avhen the action,
and injury which led to it, have both been severe—Avhen the poAver of
both part and system have been brought low—and when, in conse-
quence, gangrene is to spread—the margin of discolouration is gradually
lost in the surrounding paleness, and dark streaks are seen shooting
diffusedly upAvards in the limb.
Sphacelus, or completion of the gangrene, is indicated by the part
having become completely cold and insensible. It is shrunk in its
dimensions, soft and flaccid, almost pulpy to the touch, and crepitates
distinctly, containing not only liquid but gaseous contents,—the result
of putrescence. All vital action has entirely ceased, and the chemical
reigns paramount. The colour is black Avhen the part is exposed to
atmospheric influence ; but Avhen removed from this, as in sloughing of
the cellular tissue, or of fascia, and in necrosis—the integuments re-
maining yet entire—the dead portions retain their normal hue but little
changed.
When a part dies to a very limited extent—as a portion of skin,
cellular tissue, artery, or tendon—the sphacelated part is termed a
slough, and the process of death, sloughing.
Sphacelus being complete, and gangrene not extending, Nature in-
stantly adopts means Avhereby she may free herself from a part Avhich
is of no farther use, and whose presence may prove seriously injurious.
Its recovery is impossible ; and if allowed to remain in close contact
with the Lwing textures, these cannot fail to absorb more or less of the
noxious results of putrescence, both gaseous and fluid, Avhereby a poi-
sonous effect will be produced on the system, already brought Ioav by
constitutional disorder attendant on the gangrene. The living part, in
immediate contact with the dead, inflames; and, in consequence, the
abrupt livid line is bordered by a diffuse, red, and painful swelling—■
the line of demarcation. This vesicates ; the vesicle bursts, puriform
matter is discharged, and an inflamed and ulcerating surface is dis-
closed—the line of separation. The furroAV, so begun, gradually
deepens; at first advancing with considerable rapidity, through the
skin and cellular tissue, Avhich are prone to ulcerate \ but receiving a
check, Avhen fascia, tendon, or other fibrous texture is reached. The
advance is seldom perpendicular, but in a sloping direction ; and the
inclination is usually towards, and, as it were, beneath, the dead part,
gangrene generally being most extensive superficially. In time, ev-en
the most resisting of the soft textures are got through by ulceration,
nothing but bone remaining undivided. No hemorrhage occurs during
the gradual division of the parts ; for the inflammatory process has
passed leisurely through its ordinary grades ; the exudation and partial
organization of fibrin precede the suppuration, protecting the otherwise
loose tissues from suppurative infiltration, and sealing up the otherwise
open orifices of arteries and veins. But nature's amputation, so con-
96
PRINCIPLES OF SURGERY.
ducted, is, unfortunately, a reverse of the ordinary operation ; pro-
ducing a stump, conical, and otherwise but ill-fashioned for useful
purposes. The surgeon is, therefore, called upon to interfere in most
cases, to modify the arrangement, and secure division of the bone or
bones at a higher point.
We have been hitherto supposing that gangrene has involved the
whole thickness of a limb, the line of separation forming on the cardiac
aspect of the sphacelus, and sloping doAvnwards. When the gangrene
is less extensive, the process of separation is still the same—inflamma-
tion, suppuration, ulceration, on every aspect of the slough, until the
dead portion is fairly separated from the living. On its separation,
ulceration, still advancing, may be found beneath ; but usually it is not
so. The appearances are generally those of a healthy granulating sore.
The inflammation is seldom greater than what is merely sufficient to
secure disintegration and removal of that layer of living texture which
is in contact Avith the dead, for the purpose of separating and throAving
off the latter; and, at every point, where separation has been effected,
inflammation and suppuration pass aAvay, giving place to repair by
granulation, which slowly effects a closure of the breach. Inflamma-
tion, by ulceration, is the agent Avhich makes the furrow; repair by
granulation follows closely on its heel. And so it is in regard to dead
bone. The line of separation is scarcely visible between dead and
living, when already preparations for the substitute bone have been
begun. So quickly does restoration follow on destruction.
Constitutional Symptoms of Mortification.—During the period of in-
flammation, gangrene only impending, the constitutional symptoms are
those of Inflammatory Fever; but so soon as gangrene has commenced,
these symptoms pass more or less rapidly from the inflammatory type,
to the typhoid form of Constitutional Irritation. The disorder has been
so Avell described by Mr. Travers, in his late work on inflammation, aa
to render a transference of the passage entire more than excusable.
" The pulse is increased in frequency, and diminished in diameter
and force; in many cases irregular, and in some intermitting. A
peculiar anxiety of expression appears in the physiognomy, and a re-
markable livor overspreads the face, the features of Avhich, the nose
and lips especially, are contracted and pinched. The anxiety is soon
exchanged for a hebetude of expression, as if the patient were under
the influence of alcohol or opium ; involuntary movements and tremors
affect the hands and fingers, and frequent sighings are observed, which
are broken by occasional hiccup. The inclination for food fails totally,
the surface of the tongue is coated with a brown fur, harsh and dry,
leaving the edge and tip free, but without moisture. As the case ad-
vances, the entire tongue, fauces, and lips, become dry to incrustation,
so as to require constant moistening ; but with small quantities of fluid,
for swallowing is slow, and attended with difficulty. The skin, which
in the onset was dry, opens to a copious but clammy perspiration over
the whole surface. It parts sensibly with its temperature, and feels
cold as well as damp. The mind, at first irritable—then, after the
total subsidence of pain, stupid—wavers, and becomes subject to illu-
sions, chiefly of a passive and transient kind; expressed by half sen-
ON INFLAMMATION.
97
tences, with a thick and broken articulation, and accompanied with
startuigs and momentary gleams of insane excitement. In traumatic
gangrene—the age and constitution being previously in full vigour—
this low delirium is exchanged for fits of active and wild frenzy ac-
companied Avith loud cries and vehement efforts, requiring a powerful
and continual restraint; and this continues, Avith occasional intervals
from exhaustion, for hours together; and subsides, often suddenly, in
prolonged coma and apoplectic death." When but little of sthenic in-
dication has preceded the gangrene, as in constitutions previously
much Aveakened, or in the case of poisoned wounds inducing rapid
death of the part, the delirium continues of the passive kind. The
sphincters relax, and the excretions are passed involuntarily. The pa-
tient fumbles with and picks at the bed-clothes. More and more marked
are " the death-like coldness, the clammy sAveat, the small indistinct
and flickering pulse, and the cadaverous expression. In this state a
patient will sometimes lie totally insensible, and unable to articulate or
swallow, for eighteen or twenty-four hours, and die without a groan or
struggle."
Such is the character of that general disorder Avhich attends on gan-
grene. Death of a part is a direct shock to the frame, previously the
seat of a febrile disturbance ; and this depression is doubtless aggravated
by subsequent absorption of noxious matter from the moist and crepi-
tating mass of putrescence. The symptoms are found to vary, as is to
be expected, according to the previous condition of the patient, the
extent of the gangrene, and the importance of the part in Avhich it has
occurred. When the vital powers have been previously low; Avhen
the mortified part is vast; Avhen an internal organ has perished, even
in a patch or speck only,—the constitutional symptoms are invariably
grave, and point to a fatal issue. The patient may sink Avithin a few
hours after the commencement of the typhoid symptoms ; he may linger
on for days ; or he may rally and recover.
As certain tissues are found endowed with a faculty of resisting
ulceration, so some are less prone than others to gangrene ; those Avhich
are Avell supplied with vital power, and yet not liable to true inflamma-
tions—for example, the nervous and arterial tissues. In acute hospital
gangrene, arteries are found playing in the dark and putrid mass;
alive, whilst all is dead around them; but at length they also yield,
and death is hurried on by the hemorrhage.
When mortification occurs in an internal part, many of the ordinary
signs are of course deficient; and yet the symptoms are plain enough.
We have not the blackness, nor the coldness, nor the crepitation ; but
we have sudden cessation of pain, previously most severe; failure of
the pulse, and prostration of the strength; clammy sweat, collapsing
features, and hiccup. These having occurred, Ave may confidently look ,
for the other constitutional symptoms of gangrene, above enumerated.
In short, it is important for the practitioner to bear in mind, in the
management of acute internal inflammations—as, for instance, in the
case of strangulated hernia—that the combination of hiccup and marked
prostration, with sudden cessation of pain, plainly tells him of gangrene
9
98 PRINCIPLES OF SURGEKY.
having occurred in the part inflamed ; and that he is to frame his prog-
nosis accordingly.
Such are the results of the inflammatory process ; some antecedent,
some subsequent, to the true inflammatory crisis. Effusion of serum,
fibrin, or both, attendant on the tivo preliminary grades of action, Sim-
ple Excitement, and Active Congestion ; the fibrin organized or not,
and the effusion more or less permanent, according to the persistence
of the action Avhich occasioned it. Escape of blood, in the form either
of hemorrhage or extravasation, by casual giving Avay of the vascular
coats, during any period of the more advanced part of the process.
Formation of pus, with extravasation of blood, softening and disruption
of texture, and no organization of new deposite, attendant on the period
of true inflammation. Beyond this, disintegration and solution are
added to softening and disruption of texture, to constitute true Ulce-
ration ; denoting that the inflammatory action is continued—not only
not having subsided from its acme, but persisting until a still higher
result is attained. Or the circulation is Avholly arrested, vital func-
tion ceases, and chemical change begins; the part is dying, and dies
—not in particles, but in one continuous mass ; Mortification.
VARIETIES OF THE INFLAMMATORY PROCESS.
Many and various have been the subdivisions connected with this
part of the subject. But, for all practical purposes, it seems enough
that Ave content ourselves Avith the simple division—at once the most
ordinary and most useful—into Acute and CJironic. In the one case,
the action advances Avith more or less rapidity through its various
stages ; and having reached a climax more or less elevated—suppura-
tion, ulceration, or gangrene—declines with a corresponding degree of
alacrity. In the other the time occupied is not, as in the former, a
period of days or hours, but of weeks or months. The action begins
of a sluggish type, and retains that character throughout; dwelling long
on the minor stages ; seldom reaching to suppuration or ulceration;
and still more seldom to gangrene ; hovering rather on the other side
of the true inflammatory crisis, and, consequently, dangerous to normal
structure, by favouring fibrinous effusion and its subsequent organiza-
tion. And Avhen, having reached its climax—hoAvever low—it begins
to subside, the decline is proportionably slow, and unsatisfactory be-
cause not only tedious but imperfect.
The two forms may be commingled. The action may be at first
acute, but receiving a check, by treatment or otherwise, does not
wholly recede, but merely dwindles down into a subdued form, and
there remains, becoming chronic—chronic because moderated ; for it is
found to be a tolerably true axiom in this vital warfare, that the hotter
the action the sooner the restoration to peace ; or, in other words the
inflammatory process is not only brief when intense, and often protracted
ON INFLAMMATION.
99
when of a gentle kind, but brief because intense, and capable of lin-
gering because of a gentle grade. A part under violent action is either
soon restored or quickly perishes: under a mild form, it may bear up
for adong period. Again, the action may be at first, and for long,
chronic; but by the application of renewed stimulus, the acute form
may be superadded, or, as it Avere, engrafted on the chronic—an oc-
currence invariably fraught with imminent danger to texture ; for by
the chronic form structure has been materially changed, as well as vital
power much impaired, and the part so rendered an almost unresisting
prey to the acute attack. Such a succession of the forms is very likely
to be induced by injudicious or rash treatment, and ought to be care-
fully guarded against.
The Acute we may consider as representing the ordinary type of the
inflammatory process, and consequently to have been already discussed.
A feAV Avords will suffice to indicate the peculiarities of symptoms and
results connected with the Chronic.
Symptoms of the Chronic form.—The action being both mild and gra-
dual, the symptoms are comparatively little developed, and hence some-
times obscure. Redness, swelling, pain, heat, are slight; and of the last
two sometimes there is almost nothing. Swelling, however, though at
first slight, ultimately becomes a prominent and most important feature;
it is considerable in extent—for it has been of long continuance, and
steadily, though sloAvly, increasing; dense and firm in character—either
consisting chiefly of fibrin from the first, or the serum having been ab-
sorbed ; and tending to permanency of duration—having had time and
action both favourable to organization; there is seldom any degree of ten-
sion, for, the deposit having taken place gradually, the parts have duly
accommodated themselves to its reception. Suppuration, ulceration, and
gangrene, when attained to, are, like the action Avhich preceded them,
slow and gradual in their advance to completion; attended by the ordi-
nary symptoms of such results, in a mitigated form. Rapid and tense
swelling, with softening of texture, we sa\v to be the characteristic of
the acute form ; gradual enlargement, Avith induration, is the character-
istic of the chronic. In the latter, too, function of the part involved
may be comparatively little disturbed; a liver or a lung, chronically
inflaming, may continue their accustomed play, scarcely abated in either
amount or efficiency—at least for a time. Sooner or later, however,
function is disturbed, and that seriously.
The constitutional symptoms are proportionally mild. Febrile dis-
turbance may be so slight as scarcely to be appreciated by either the
patient or his attendant, especially if the action be seated in an internal
part; Avhen perceived, it is often both so obscurely marked and so
transient, as to baffle or deceive in the effort of tracing it to its cause.
The most prominent symptoms are Avant of refreshing sleep, loss of
appetite, emaciation, change of colour in the general surface to a pale
or dirty yellow, occasional flushes, sensation of cold, and frequent in-
clinations to shiver, impairment of strength, and a general feeling of
uneasiness; the patient feels that he is ill, yet scarcely knows how or
where. In the severe forms the febrile condition is more marked, and
partakes, more or less, of the inflammatory type—headach, heat, fre-
100
PRINCIPLES OF SURGERY.
quent and hard pulse, dry skin, scanty urine, thirst, restlessness ; yet,
the local action remaining chronic, the fever never attains to the form
of the true inflammatory ; it is less sthenic, less marked, less progressive,
less continued. The tendency to remission, sometimes almost com-
plete, is one of its most distinctive characters ; the period of exacerbation
is evening, or the early part of the night: morning, that of remission,
with or Avithout perspiration. Sometimes the local action itself assumes
somewhat of the remittent character ; seeming to have abated or even
ceased during several days, Avhile all the time it Avas steadily, though
stealthily advancing.
It should never be forgotten that, however slight, and apparently
trivial the constitutional symptoms of the chronic inflammatory process
may be, yet, by their mere persistence they are likely to exhaust the
frame, and induce a fatal termination.
On the occurrence of suppuration, they readily change into those of
hectic. Gangrene having taken place, the typhoid form is as speedily
assumed, Ioav, and tending still dowmvards, from the beginning. An
acute accession having been unfortunately superinduced, the true in-
flammatory fever may be assumed, at least for a time ; but more fre-
quently the effect towards sthenic action is but partially successful, and
results in the irritative form of fever.
The Results of the Chronic Inflammatory process are thus seen to be
chiefly formidable by the long continuance of the action, and the in-
sidious nature of its progress ; change of structure, all but irreparable,
may have occurred before the attention of either patient or practitioner
has been directed to the part. Gradual alteration of structure is the
most ordinary result; by interstitial deposit, of a fibrinous kind, be-
coming more or less organized. Suppuration, ulceration, gangrene,
though comparatively rare, yet may and do occur; they can scarcely
be avoided, if the chronic form of action have for some time existed,
and suddenly become merged in an acute inflammation.
THE MANAGEMENT OF THE INFLAMMATORY PROCESS.
Prevention.—Therapeutic means applied immediately after removal
of the exciting cause, may have the effect of entirely frustrating its
ordinary operation, and preventing perverted vascular action. For this
purpose the period of incubation must be diligently improved. But to
insure success, it is not only necessary, as can be readily understood,
that the suitable means be early and sedulously employed, but also that
the cause shall have been slight as well as transient; that its removal
shall have been entire ; and that the part have its vital power as yet
unimpaired. The first effects of the stimulus Ave saw to be an impression
on the nervous system, if not itself morbid, at least tending to a morbid
result. The first object of preventive management is tc° mitigate or
remove this. By some, hot water, or its steam, is applied constantly;
and it succeeds in more or less subduing the nervous excitement__or
breaking off the first link in the chain. But the second step of the
ON INFLAMMATION.
101
initiatory process, seldom far disjoined from the first, Ave saw to be
excitement of the vascular system of the part; and this system is likely
to be further stimulated by the heated applications by Avhich the other
is soothed. Cold, continuously applied, is therefore, in my opinion,
preferable ; inasmuch as it is likely to fulfil a twofold indication, by
exerting a sedative or depressing effect on both the ner\rous and vascu-
lar systems of the part, and so rendering the accession of the process
still more improbable ; absence of the first two links of the chain is very
likely to frustrate the formation of the Avhole. But this simple remedy
requires nicety and care in its application. The first effect of cold, as
formerly stated, is sedative, the second reactive ; the first opposed to
vascular action, the second inviting its occurrence ; the first Ave de-
siderate, the second we wish to avoid. To be prophylactic, therefore,
its application must be continuous ; if interrupted, hoivever briefly, re-
action is imminent—not only to arrest, but to undo the good effects of
all the previous precaution. The most convenient mode of application
is to cover the part by a loose layer of fine lint, and have a trustworthy
attendant to keep this constantly moist and of Ioav temperature, by cold
water frequently and gently dropped on it out of a sponge ; the slightest
dryness or Avarmth being dreaded as a source of disaster and disap-
pointment. Or the assistant may be dispensed with, and a process of
constant irrigation employed; a thin strip of lint communicating, syphon-
like, Avith the lint on the part and a water-vessel placed in its immediate
vicinity. The bed-clothes, if need be, are protected by the interposi-
tion of oil-cloth, arranged slopingly, so as to favour the draining away
of the Avater, after it has trickled, in a constant though tiny stream, on
the seat of injury. Besides, the part is to be kept rigidly quiet, or at
least as much so as circumstances will possibly permit; and it should
be also so placed as to favour venous return and oppose arterial influx,
at the same time relaxing those muscles Avhich are either directly or
indirectly implicated. Both mind and body should be placed and kept
at rest; and Ioav diet, Avith abstraction of all stimuli, Avhether local or
general, must be rigidly enjoined. Parts simply stimulated—that is to
say, without wound—may by such treatment be altogether saved from
inflammatory accession ; and many incised Avounds may thus be brought
to rapid and almost painless healing, by adhesion—the inflammatory
process not having been wholly prevented, but so subdued and limited
as never to reach even the vicinity of the true inflammatory acme.
It is only sometimes that we are able to prevent every part of the
inflammatory process ; but in many cases Ave may thus prevent that
advancement Avhich constitutes true inflammation.
Treatment.—Removal of the cause ought assuredly to be the first care
of every practitioner Avho is called on to subdue the inflammatory pro-
cess. That preliminary point having been successfully carried, he will
then be enabled to attain his principal object by the use of comparatively
slight means ; with little trouble to himself, and at the expense of com-
paratively little pain, annoyance, delay, or danger to the patient.
Whereas, let the all-important preliminary step be either neglected or
imperfectly secured, and all the most powerful remedial means may be
102
PRINCIPLES OF SURQERY.
unceasinglv employed, with little or no avail. Nothing is more com-
mon than a patient to apply for relief, on account of nascent inflamma-
tion of the conjunctiva, caused by the lodgement of foreign matter in
that membrane. Remove the particle of dust or sand at once ; and
then, fomentation, a shade, a purge, careful diet, and perhaps a few
leeches, will, in the great majority of cases, suffice to dissipate even the
most formidable of such ophthalmiae, within a few days at the utmost.
But, on the other hand, leave the foreign matter imbedded in the in-
flaming part; and then, leeches innumerable, bleeding from the arm or
from the temporal artery, once and again, blisters in almost endless
succession, purges, antimonials, mercury pushed to profuse ptyalism,
and perhaps repeated—in short, ruin to the system by severity of treat-
ment may be enforced and endured, Avithout arresting the action, or
preventing loss of vision by irreparable change of structure. And this
is not mere fancy. Cases are on record of eyes having become pearly
white and sightless, notwithstanding the induction of anaemia, dropsy,
and mercurial disease—premature age and infirmity—by the attempts
to save ; all the while, some small particle of foreign matter lodging
undisturbed, and probably unsuspected, in the lining of the upper
eyelid—whose simple removal might have saved both eye and system
to the patient, as well as credit and conscience for the practitioner.
Our first duty is to inquire carefully for the exciting cause. If
already removed, good and well; if still in operation, we are to procure
its abstraction as speedily and effectually as may be in our power.
And then Ave are in a favourable position to proceed with the directly
remedial means—those which are opposed to the advance and per-
sistence of the inflammatory process, and consequently termed Anti-
■phlogistics. The most important of these is blood-letting; and the blood
may be taken either from the part, or from the system at large.
1. General Blooddetting.—In the outset it is to be observed that this
is not invariably necessary. It is a spoliative remedy of the highest
class, and therefore never to be had recourse to, unless circumstances
declare it either imperatively demanded, or at the least highly expe-
dient. There is every reason to fear that this little operation—after-
wards to be described—is too frequently employed; frequently, because
heedlessly—Avhen it might have been well superseded by other and
more gentle measures, or Avhen actually no benefit, but sad injury,
floAved from and Avith the " purple stream." It is a very easy matter
to take away blood, and thereby induce debility; Avhile to undo that
result, is in most cases difficult, and often impossible. Congestions,
serous effusions, bloodless cheeks, atrophied and all but palsied mus-
cles, a withered frame and an enfeebled mind, may remain, silent yet
steadfast and truth-declaring witnesses of the error in practice. On
the other hand, the practitioner will be equally culpable by refraining
from this operation, when the circumstances of the case call plainly
and loudly for its performance. And it may be stated broadly that
general blood-letting is required ; when the inflammatory symptoms-
local, general, or both—are severe—as in many examples of phleg-
monous erysipelas and compound fractures ; when the part affected ?9
of importance in the animal economy—as the lung, bladder or kid-
ON INFLAMMATION.
103
ney ; pr when a delicacy of texture is involved, whose maintenance is
essential to function—as in the eye, in the synovial membrane, and in
the nervous tissue in general.
The bleeding is not to be regulated by its absolute amount, but by
its effects. No idea should be entertained that in one form of disease
a certain number of ounces will suffice, while in another a greater, and
m a third a less amount must be invariably taken. In every case, the
thought of measure is to be abandoned, and the blood permitted to
flow on until the desired effect has been obtained ; then the stream is
arrested, irrespective of whether the ounces amount to three or thirty.
And in connexion with this point, it is farther to be remembered, that
true inflammation engenders a tolerance of this remedy. A young,
robust, healthy man, may be bled when he does not require it; but
most probably twelve or fifteen ounces shall not have flowed, ere na-
ture interposes her objection to the procedure, and syncope is produced.
Whereas, open a vein in the arm of even a weak, pale-faced, nervous
patient, who is the subject of-an acute inflammatory seizure in some
important part, and it is not improbable that double that amount, or
more, shall have been withdrawn ere any considerable effect has been
made upon the patient's system. So truly and generally does this ob-
tain, that an important auxiliary in diagnosis may be thence derived.
You are bleeding a patient, in doubt Avhether the disease is truly in-
flammatory or not, but you suspect that it is, otherwise it is likely you
would not have performed venesection; only a feAV ounces have
escaped, when the patient groAvs pale and faint; you arrest the flow,
and reconsider your diagnosis, suspicious of an error. But should no
faintness threaten after a full or even large abstraction, doubt is re-
moved, your diagnosis is confirmed ; you advance unhesitatingly with
the antiphlogistics ; the disease is there, and has engendered a tole-
rance of the remedy. On coming to a conclusion from this source,
hoAvever, care must be taken to ascertain that the syncope, or tendency
thereto, is an actual failing of nature, the effect of the loss of blood,
not the result merely of fear or other depressing agency on the patient's
mind. When aAvare that the patient is naturally timid, and liable to
faint from this cause, and Avhen at the same time confident that he
labours under true inflammation, and that the circumstances demand
effective blood-letting—we will bleed him in the recumbent posture,
and with a gentle stream.
Tolerance of bleeding will also be found to vary according to the
sex, age, and temperament of the patient, caeteris paribus ; greater in
the male than in the female ; greater in adult age, than at either of the
extremes of life—in early infancy it is most especially small—in ad-
vanced years it is not likely to prove so obviously and directly calami-
tous, yet is a spoliation hard to be borne ; least in the nervous, greatest
in the sanguine temperament.*
* Tolerance of bleeding in inflammation is attributed by Dr. Williams to " increas-
ed excitability of the heart and tonicity of the arteries, which maintain a sufficient
force and tension to preserve the circulation, especially through the brain, even when
much blood is lost. In asthenic or atonic diseases, on the other hand, the arteries be-
ing lax, and ill-fitted to transmit the blood, a smaller loss is felt, and syncope may
result."
104
PRINCIPLES OF SURGERY.
Similar tolerance of appropriate remedies seems often to bo generated
by disease In fact it may be laid down as almost a general rule, that
a remedy—in itself severe—appropriate to a given form of disease,
may be administered in even large quantity during the persistence of
that disease, with not only relief to the symptoms, but with comparative
impunity to the system at large ; whereas the same remedy, given even
with a sparing hand, while no such call for its employment exists, is
certain to affect the constitution injuriously. In nervous disorders, as
one form of delirium tremens, opium can be given in doses, a tithe of
which would fatally poison the person if in health. In inflammation of
the lungs, tartrate of antimony is given to an extent which would,
under other circumstances, be absolutely intolerable. _ In iritis, syno-
vitis, and certain forms of the venereal disease, in which the use of
mercury is not only expedient but essential, that mineral can be pushed
Avith safety; it is to the sakeless salivations—errors either of judgment
or of diagnosis—that the ruin of mercurially-shattered frames is attri-
butable.
The effects of general blood-letting, in so far as they are remedial of
inflammation, are, 1. A sedative result on the heart's action, on that of
the arterial trunks, and thus on the general circulating system ; effected
partly by withdrawal of its Avonted stimulus, the blood, from the cen-
tral organ ; and partly by the depressing effect of sudden loss of blood
on the nervous system, which reacts in a corresponding strain upon the
circulating. And this sedative effect on both heart and arteries is
proportionally indicated, by diminution of the hardness and thrilling of
the pulse, as well as of its fulness and frequency. It is plain hoAv such
lull of the general circulation is advantageous, as regards both the local
action and the fever Avhich accompanies it. 2. The blood is diminished
in absolute volume. In some cases this is not desirable ; on the con-
trary, Ave may be not more anxious to crush rising inflammation, than
to husband the vital resources already Aveakened, and especially to
retain this all-important fluid umvasted and undiminished ; Ave therefore
bleed sparingly, if at all. Yet there are cases in which the blood is
preternaturally increased in quantity, as well as changed in character—
as in inflammation occurring during well-marked plethora ; in such cir-
cumstances diminution of volume will favour resumed general control
of circulation, at the same time lessening the probability of sanguinous
determination to any individual part. 3. The blood is also affected
somewhat as to its component parts. These do not pass out from the
open vein in their ordinary and equable proportions, but some more
than others ; at first the red corpuscles escape most freely, and then
the proportion of fibrin also is found to have sensibly diminished.
Physiology scarcely enables us yet to reason accurately on the effects
of such change ; but it is not unreasonable to suppose, that by thus
parting Avith the oxygen-carriers, and with the matter of true plasma,
heat and perverted nutrition—two sufficiently prominent symptoms of
the diseased action—may be mitigated. 4. Derivation of blood is
effected from other parts—the inflamed probably benefiting in an
especial degree—to that whence the blood issues. HoAvever this is
effected—whether according to mechanical or vital laws, or both__
ON INFLAMMATION.
105
microscopical observation, corroborating what had been previously
inferred from experience, has established the fact, that it does occur.
Have -an inflamed part beneath the field of the microscope, and draw
blood by a puncture from another, even distant point; blood will be
seen actually leaving the part inflamed to meet the increased demand
elsewhere; and even stagnant portions will be seen to disentangle
themselves, and resume a brisk movement for the same purpose. This
derivative effect is plainly in.favour of the burdened part. It may be
that it is but temporary, ceasing almost with the flow that caused it.
Yet granting such to be the case, still an important advantage has been
obtained; inasmuch as even this temporary relief may be such as to
enable the capillaries in some degree to recover their tone, and the
parenchyma to accommodate itself better to the temporarily diminished
effusion. 5. The action of other remedies is facilitated. " By lessen-
ing that morbid impetus of the blood (and increased tone of the vas-
cular coats) by which during the state of inflammatory fever the natural
excretions are apparently impeded, and at the same time by promoting
absorption into the blood (as loss of blood is Avell known to do) it fa-
vours the effect of all other evacuating remedies intended to act on
the excretions of individual parts of the system."* And farther, by
its precedence, it renders certain remedies—as mercury and opium—
decidedly beneficial, Avhich otherwise would have proved either inope-
rative, or absolutely injurious.
These beneficial results of blood-letting are materially affected by
the manner in which the blood is Avithdrawn. As already stated, it is
desirable, in the great majority of cases, to obtain the effects, more
especially the sedative, at a cost of as little blood as possible ; and with
this view, the manner of abstraction becomes all-important. Make a
large orifice in a vein or veins, let the blood escape in a rapid, full
stream, with the patient in the erect or semi-erect posture, and syn-
cope is soon arrived at; these circumstances tending to sudden with-
draAval of Avonted stimulus from the heart, and diminution of arterial
supply to the brain. Whereas, blood may be taken in large quantity—
especially Avhen tolerance by disease exists—from a small aperture, in
a slow and small stream, during recumbency ; in fact, the system may
be thus almost Avholly drained of blood, ere faintness threaten to ensue.
And thus Ave see how sIoav venous hemorrhages, of accidental origin,
prove so dangerous ; faintness, so favourable to the spontaneous and
effectual arrest of the flow, by formation of coagulum, is too long de-
ferred. Syncope may be, in truth, regarded as nature's safeguard from
hemorrhage. In the case of accidental wounds, it usually supervenes
ere actual danger has accrued from the loss, allowing the vascular ori-
fices to contract and become occluded by coagula. When blood is
designedly taken in the treatment of disease, and Avhen it is proper that
blood should be so taken, there is tolerance ; or in other Avords, syn-
cope remains in abeyance till a sufficiency shall have floAved. But
should an error of judgment have been committed by the practitioner,
nature is ever watchful to retrieve it; and where blood is flowing
* Alison.
106
PRINCIPLES OF SURGERY.
when it ought not, very little is lost ere syncope ensues, and arrests tha
stream.
In antiphlogistic bleeding, then—except in the comparatively few
cases in Avhich actual loss of blood is desirable—the abstraction ia
made rapidly, in the erect or semi-erect posture. But syncope is to be
approached rather than actually attained. Our object is, not only to
produce, but to maintain a sedative effect on the heart and general cir-
culation ; if syncope occur, reaction is almost certain to prove exces-
sive ; Avhereas, if the immediate result be less extreme, it is more easily
retained; by stopping short of actual syncope, excessive reaction is
rendered both less probable and more readily controlled. Besides, a
fainting-fit may prove in itself somewhat dangerous ; if there be either
organic disease in the heart, or a considerable effusion in the pericar-
dium, the cessation of the heart's action may prove permanent, ^o
soon, therefore, as the symptoms of approaching syncope sIioav them-
selves, we usually desist from blood-letting; Avhen the patient grows
pale, and articulates faintly and Avith difficulty ; Avhen he begins to fail
from the semi-erect posture, sighs, and slums signs of nausea; Avhen
the lips groAV dry, white, and quivering, the eyes dull and glassy, and
a cold siveat bedews the face and forehead; when the pulse becomes
weak and fluttering—then Ave bind up the arm, and place him gently
recumbent. From twenty to thirty ounces may be estimated a fair
average first-bleeding, in a case of inflammation attacking a robust
adult; but, as already stated, it is better to keep mechanical admea-
surement altogether out of the question,
From the depression by bleeding the circulating system rouses itself,
more or less rapidly, and the result is termed reaction. This either
remains of a tolerably quiet and subdued character, the inflammation
having simply given way; or it becomes excessive. And excessive
reaction may be of tAvo kinds. 1. It may be of an asthenic or ner-
vous character, indicated by rapid, soft, and jerking pulse, oppressed
breathing, headach, and tinnitus aurium, general nervous excitement,
and non-return of the ordinary inflammatory symptoms—a state of system
very similar to what follows on simple loss of blood in large quantity.
To bleed again would be to aggravate such disorder. A full opiate ia
administered; the nervous excitement is allayed, the patient falls
asleep, and aAvakes with a calm pulse and system, relieved as if by the
working of a charm. The opium here does not create the sedative
impression on the circulation; given by itself, it most probably Avould
not only have failed to quiet, but have increased the tumult; but
coming after bleeding, it restores the sedative result which this had
achieved, but Avas unable singly to maintain. 2. But reaction may be
of an opposite kind—sthenic ; in fact, a continuance or re-accession of
the inflammation. The pulse is hard and vibratory as before ; the
fever still retains the inflammatory character ; local heat and pain are
still unsubdued. The inflammatory process has been interrupted, but
not arrested; the remission proves but transient, and the re-accession
may be more fierce than the original onset. This must be met by the
lancet. A sound bleeding is to be; practised, so soon as such reaction
has declared itself. A few ounces drawn then will suffice to restore
ON INFLAMMATION.
107
the sedative effect of the former bleeding; while double the original
amount may fail to make a satisfactory impression, after time has been
allowed for the re-accession to make head and be established.
The paramount importance of time, in connexion Avith blood-letting
as an antiphlogistic, should never be forgotten ; Avhether it be practised
to crush the rally, or meet the original attack. Comparatively speak-
ing, one full bleeding of ounces, drawn early—just at the onset—will
be far more available as a remedial agent than quarts taken at a sub-
sequent period ; and then not only will the cure be less complete and
satisfactory—change of structure having occurred by effusion, and reso-
lution proving both gradual and incomplete—but to obtain this second-
ary result, the system must be sadly shaken by the severity of the treat-
ment employed. " Obsta principiis" is the invariable motto of the
antiphlogistic phlebotomist.
The signs of bleeding having proved effectual are, in general, suffi-
ciently plain. The pulse loses its hardness and thrilling, becoming soft
and compressible ; it may be more or less frequent than before, often
the former, at least in the first instance. The pain and heat either
cease in the part, or continue in a mitigated form ; the other ordinary
signs recede; function returns, both in the part and in the system ; secre-
tion, general and local, is restored ; and usually the blood, Avhen drawn,
ceases to exhibit the inflammatory character. It must be borne in mind,
hoAvever, that this result is not invariable. Exceptions to the general
rule in this respect are by no means unfrequent; and blood may be at
least buffed, if not cupped likeAvise, notwithstanding that the inflamma-
tion has given Avay ; Avhile, on the other hand, action may be persisting,
while the blood seems scarcely sizy. It therefore folloAvs that, in either
case, Avhen the evidence of the blood is opposed to that of the other
inflammatory signs, the latter are to be believed and to guide the prac-
tice ; but usually they will be found to agree in one indication.
Certain circumstances materially affect the practice of blood-letting,
and ought ahvays to be taken into consideration. 1. The duration of
the action. At its commencement, general bleeding may be expected
to produce the happiest results ; at a more advanced period, a greater
quantity of blood must flow, but still the effect may be in the end satis-
factory ; but after some considerable time has elapsed, the system may
be drained of blood to an absolutely ruinous extent, and yet little im-
pression may be made thereby upon the local disease. 2. The age,
sex, temperament, and occupation of the patient. The first three have
been already noticed as affecting the tolerance of the remedy. Occu-
pation is equally important. The robust and temperate peasant will
require a larger bleeding, and bear it better, than the pale and too often
dissipated inhabitant of the crowded city. And, again, among the lat-
ter class important variety is found ; some—brewers' servants for ex-
ample—being found especially intolerant of this remedy. 3. The
nature of the part affected. Many an inflammation of an external part
requires no general blood-letting; while the inflammatory process can
scarcely alight on any internal and important organ, without not only
demanding this remedy, but apparently imparting to the system power
to bear the necessary spoliation. 4. The state of the system previous
108
PRINCIPLES OF sunr.KRV.
to the inflammatory attack. The patient may be plethoric ; we may
then bleed almost recklessly, and in the recumbent posture ; better con-
tent with a large than a small amount of ounces. He may have been
anaemic ; Ave either forego venesection altogether, or practice it most
cautiously, using e\-ery means in our poAver to secure the desired effect
with the least possible expenditure of the valuable fluid. 5. The ulte-
rior result. After severe mechanical injury, it is very desirable to limit
the secondary occurrence of gangrene, and the obvious means of doing
so is by active antiphlogistic measures to mitigate the action Avhich is
setting in ; but in effecting this object, blood must be taken sparingly
and Avith much caution, seeing that a certain amount of gangrene is
inevitable, attended with its usual constitutional symptoms of depres-
sion ; and on separation of the sloughs, a profuse and hectic-causing
suppuration is equally certain to ensue. It may be very easy, by heroic
expenditure of blood, to attain the object immediately in view ; but, in
all probability, it will be very difficult to prevent the rash levelling
blow, Avhich arrests inordinate action, from at the same time annihilating
the patient's chance of ultimate recovery.
Blood may be draAvn from the general system either from an artery
or from a vein—arteriotomy, and venesection or phlebotomy. When the
former is practised, a superficial branch—usually the anterior—of the
temporal artery is generally selected. Blood can be thus taken both in
large quantity and Avith much rapidity, so as to secure the desired seda-
tive effect; but it is an operation Avhich demands more dexterity in
performance than venesection, and is, besides, not unlikely to be fol-
lowed by troublesome consequences, as will afterwards be explained.
A subcutaneous vein, on the contrary, is superficial and easily reached.
Blood can be draAvn both rapidly and in quantity, if need be, by means
of a large orifice; arrest of the Aoav is more easily effected than in
wound of an artery, and the incision is more likely to unite simply by
adhesion. Hence, venesection is usually preferred ; and the points of
selection are, one of the veins at the bend of the arm, for general pur-
poses ; and the external jugular vein in the lower part of the neck, in
certain cases; operations which will be duly treated of in the depart-
ment of special surgery. In many patients, especially females affected
with obesity, it is not always an easy matter to reach a vein at the
ordinary sites ; but when foiled there, it does not inevitably follow that
arteriotomy is the only other resource. For, if venesection be rendered
preferable by circumstances, it is to be remembered that a sufficient
vein—the cephalic—is always to be found by a slight and sure incision,
placed in the interspace between the deltoid, and the clavicular portion
of the pectoralis major muscles.
Hosmostasis, or temporary arrest of a portion of the blood, apart from
the general circulation, has been proposed, as an occasional, or, per-
haps, even frequent substitute for blood-letting ; or, at all events, as an
useful auxiliary.* The blood of a limb, or of limbs, may be readily
retained therein for some time, by deligation sufficient to arrest the
venous return; and this may possibly have the effect of relieving the
* Maryland Medical and Surgical Journal, March, 1843.
ON INFLAMMATION.
109
general circulation ; the sluices being afterwards slowly opened, so aa
to permit the gradual escape of the pent-up fluid. Such procedure is
sufficiently ingenious, and not unpromising in theory ; but it requires
attestation by experience ere it can be recommended in practice.
2. Local Bleeding.-—This is usually associated with general blood-
letting—securing relief of the part as well as of the system. It operates
beneficially on both—on the part, by removing, or, at all events,
diminishing its sanguineous burden; on the system, by keeping up the
sedative effect on the general circulation, Avhich the general bleeding
had previously produced. And, further, it is to be borne in mind how
constitutionally important is the early use of such a remedial agent
directly affecting the part, inasmuch as that part being the laboratory
whence issues the inflammatory change of the blood, the sooner the
inflammatory process is arrested therein the less A\ill be the probable
amount of febrile disturbance in the system.
But, under certain circumstances, the local is preferable to general
blood-letting, and supersedes it altogether. 1. When the inflammatory
action is trivial in itself, and situated in a comparatively unimportant
part, there is no reason, but the contrary, Avhy the system should suffer,
when local remedies are perfectly adequate to the subjugation of the
local disease. We do not " raise a storm to droAvn a fly." 2. When
the poAvers of the system have been low previous to the inflammatory
accession. General bleeding being obviously from this cause inexpe-
dient, and the local change having not advanced so far as to create a
fictitious tolerance of it, Ave content ourselves with a local depletion;
but sometimes we may carry that so far as to approach in its effects the
severer form of the remedy. 3. When the inflammatory process has
been fully established, and is far advanced by continuance. It. has
been already observed, that in such circumstances even a great loss of
blood from the arm will probably fail to produce a remedial effect on
the part; to practise it would be to Aveaken the frame unnecessarily.
Local bleeding, even though frequently repeated, will occasion much
less general exhaustion, Avhile it is dealing successfully Avith the disease.
4. Either extreme of age forbids general bleeding, unless in extreme
circumstances; indeed, in both the very young and very old, local
bleeding, when at all considerable, is in its effects tantamount, or nearly
so, to the general; the latter will, in the majority of cases, prove not
only unnecessary to the treatment, but absolutely intolerable to the
system.
A general rule applicable to local bleeding has been much insisted
on by M. Lisfranc, and not without good shoAv of reason ; namely, that
blood, Avhen draAvn with an antiphlogistic object, should not be taken
immediately from the affected part, unless in large quantity. A few
leeches, placed in the near vicinity of an inflaming part, relieve, by
drawing blood from it. They are antiphlogistic by derivation. The
same number, placed on the part, draw blood from the parts around to
the source of the Aoav, and thereby tend to increase sanguineous de-
termination, instead of relieving it. If direct application is to be em-
ployed, the quantity taken must be large, truly spoliative ; as it were
emptying the part, notwithstanding its borrowed supply from the vicinity.
110
PRINCIPLES OF SURGERY.
Local bleeding, therefore, to be antiphlogistic, must either be small in
amount, and indirect in its extraction, or direct and copious. Let it be
the latter, when a constitutional effect as well as local is both expedient
and permissible ; the former, invariably, Avhen Ave are anxious to hus-
band the general \dtal poAvers, and to attack only the local malady.
The foregoing observations, of course, do not apply to abstraction of
blood directly from the part by puncture, scarification, or incision;
these, hoAvever slight or few, cannot fail to rifle the part of its fluid con-
tents, and, besides, they have other fully as important indications to
fulfil.
Blood is withdraAvn locally in various ways—by cupping, leeching,
puncture, scarification, incision.
Cupping.—This, Avhen the means are at hand, and the nature of the
part is suitable to their application, is, perhaps, the preferable mode-
less tedious and annoying than leeching, and likely to prove also more
effectual. Rapidity of abstraction we saAv to be useful, in obtaining a
sedative effect on the system. Probably it is similarly useful when
directed upon the part. Much blood may require to flow by theslow
oozing of leech-bites, ere the spoliative and sedative result is obtained.
Half the quantity, suddenly removed by cupping, may prove equally
or even more successful.
This little operation is performed in the following manner:—The
surface is first hotly sponged, and then the cups—duly exhausted by
the spirit-lamp—are fixed on the parts whence the blood is to be taken;
this creates a determination to that portion of the surface; at once
facilitating the abstraction of blood, and causing a derivation itself
favourable to the inflaming texture. By heat and moisture this deter-
mination to the surface is maintained throughout the operation. The
cups having been removed, the scarificator is instantly applied fc> the
red and swollen parts; and the incisions are made deftly, with the
instrument pressed lightly on, and Avith the range of the lancettes so
modified that they shall penetrate not more deeply than the true skin,
otherwise the adipose tissue will fill the wounds, and arrest the flow of
blood. The scarificator, so soon as it has been discharged, is replaced
by a hot sponge, and this again by the glass fully exhausted, yet not too
much so, otherwise the pressure may be so great as to obstruct the cir-
culation of the part. The changes are made as rapidly as possible.
The blood, as it escapes more or less freely, rises to fill the vacuum;
so soon as it begins to coagulate, or sooner if the flow be tardy, the
glass is removed, emptied, and reapplied, freshly exhausted. On each
reapplication, it is well to shift the glass slightly from the former site,
so that the pressure of its rim—often severe—may not be injuriously
concentrated on one and the same circle of integument. During the
interval of reapplication a warm sponge covers the wounds; and on
leaving is made to rub them somewhat rudely, in order to prevent the
lodgement of coagula. Detachment of the glass is effected carefully,
by pressure of the finger applied to the uppermost part of the rim ; the
glass, thus loosened by entrance of the atmospheric air, is slowly bent,
as it were, downwards, a sponge pressing firmly on its rising edge, so
as to sweep all the blood into its interior, leaving the bed and body
ON INFLAMMATION.
Ill
clothes unsoiled. The number of glasses, and of their reapplication,
are varied according to the amount and rapidity of abstraction desired ;
the average product of a single glass may be held as ranging from four
to six ounces. If the glass be placed over aAvound or wounds, fed by
a distinct arterial branch—such as the anterior of the temporal artery—
the portion of the rim Avhich overlays this vessel, on its cardiac aspect,
is to be a little raised, so as to permit free arterial influx, otherAvise the
bleeding will prove but scanty. Abstraction over, the parts are lightly
and cleanly sponged, and covered by some simple adhesive plaster;
usually they heal readily by adhesion. But it may be desirable that
they should not do so ; the case may be such as to render advisable
the early succession of counter-irritation to local bleeding ; the Avounds
are then treated by stimulants, so as to favour inflammation and suppu-
ration, and the scarified part is thus speedily and easily converted into
a suppurating issue.
Much ingenuity had been expended in adapting apparatus to the per-
formance of this operation; but I believe that all modifications have,
each in their turn, been found inferior to the ordinary mode by simple
glasses exhausted by the spirit-lamp. Much practice, however, is
necessary, ere the dexterity of a neat and successful manipulator can
be acquired.
Leeches can be used when and Avhere cupping-glasses and scarifica-
tors can not. Their application is simply effected by confining them
in a glass or wire-gauze receptacle, which is inverted, and held steadily
till they fasten on the part whence we Avish the blood to issue ; they are
thus effectually prevented from spraAvling abroad diffusedly, as their
caprice would probably lead them. The part is previously made
smooth by abrasion, and clean by ablution, especially if foetid or other-
wise noxious matter have been formerly applied. Appetite is increased
in the animals by their being dry, both outside and in ; on this account
they should be kept for some time out of Avater, and gently dried with
a soft towel, before application. If still sIoav to bite, they may be
briefly immersed in warmish porter; and the- part may be smeared
either Avith a little SAveet cream, or with blood freshly draAvn from a
puncture. When the animals have filled and loosened, the part is dili-
gently and hotly fomented, so as to encourage oozing from the aper-
tures ; and by this the greater part of the bleeding will probably be
taken. Each leech, or rather each leech-bite, may be rated at about
an ounce and a half. Sometimes the hemorrhage is troublesome by
continuance from one or more of the apertures. Let firm, direct, dry
pressure be maintained for a short time, and this will probably be suffi-
cient for its arrest. If not, insert the point of a finely pencilled portion
of nitrate of silver carefully into (not on) the aperture ; press steadily
with it there for a few seconds; and immediately on its removal apply
a dry compress, retained by either the finger or a bandage. It is not
often that this procedure is demanded; and still more rarely does it
fail, when duly practised. If it should, transfix the part by a fine
needle, and encompass this firmly by a ligature, as in the formation of
the " tivisted suture." Troublesome bleeding is most likely to occur
in children, more especially if the leeches have been applied to parts,
112
PRINCIPLES OF SURGERY.
not only of active circulation, but also exposed to cons ant or frequent
motion, as in the neck. And it is a safe general rule, applicable to
leechino- at a tender age—Avhen, as we have seen, much bleeding is
but ill borne—that the patient be not left, particularly over night, until
the bleeding has fairly ceased. To leech a child on the chest or neck,
cover the part Avith a large hot poultice, and leave it thus for some
hours, is to encounter a great hazard of the patient's perishing by
hemorrhage. In regard to children, it should further be remembered,
that the loss of blood by a few leeches is equivalent to a full bleeding
from the arm in an adult; that in them, in short, a local is equal to a
general blood-letting. " Three leeches, bleeding well, are a full bleed-
ing for a child of one year, at least of the average strength of those
brought up in great towns ; and if one is added for each year of the
child's age up to five, a fair number for a single evacuation may be
obtained. Beyond this age, in strictly inflammatory cases, bleeding at
the arm is certainly to be preferred."*
But there are other precautions to be regarded, in the application of
leeches :—1. They should not be placed where there is either frequent
or constant motion, as on the neck, or over the costal cartilages ; other-
wise the bleeding is not unlikely to prove troublesome. 2. Nor should
they be placed on parts habitually exposed, especially in females;
othenvise the cicatrices may prove unseemly. And when it is remem-
bered that local bleeding, unless in large quantity, is usually more
effectual, Avhen indirectly than directly taken from the part, we shall
seldom find it difficult to fulfil the foregoing indications. 3. In children
it is Avell to avoid large superficial veins, especially in the neck. 4. Nor
should they be placed Avhere the fibro-cellular tissue is peculiarly lax
and delicate, as in the eyelids; othenvise ecchymosis, acute oedema,
or both, are apt to ensue. 5. Nor Avhere subcutaneous nerves abound,
otherwise much pain will be occasioned, and the occurrence of either
erysipelas or angeioleucitis rendered not unlikely ; in the case of the
fore-arm, for example, the dorsal will be preferred to the palmar aspect.
6. They should not be placed directly on the part inflamed ; for (1.)
unless in sufficient numbers to prove spoliative, their effect will not be
antiphlogistic, but the contrary ; and (2.) because they are apt to prove
irritant, and, by adding fresh stimulus, to hurry on instead of arresting
the inflammatory process. For example, punctures are more suitable
than leeches to an erysipelas. 7. They should not be placed in the
immediate vicinity of an acute ulcer, more especially if this be of a
specific kind ; othenvise the bites are apt to be inoculated, and conse-
quently to degenerate into ulcers, so extending instead of limiting the
evil. 8. Nor should they be applied, unless considered truly indis-
pensable,where bandaging or other retentive means are of paramount
importance, as in fractures of the limbs ; for, under such circumstances,
the wounds are apt to inflame and ulcerate, compelling a discontinuance
of the most important part of the apparatus, and probably at a critical
time of the cure.
Blood may also be taken from a part by punctures, as in simple
* Alison.
ON INFLAMMATION.
113
erysipelas; by scarification, as in inflammatory affections of mucous
membrane—the eyelids, for example ; by incision, as in urgent phleg-
monous erysipelas. But in addition to abstraction of blood, these
wounds perform the more important indication of Avithdrawing the in-
flammatory effusions—serous, fibrinous, and purulent—and thereby af-
fording most important relief to the part; not only removing what has
been already exuded, but affording a ready exit to the coming effusion,
instead of its being infiltrated into the surrounding texture.
3. Purgatives are generally an important item of the antiphlogistic
catalogue, and are used early. They disburden, by clearing away ac-
cumulated matter from the intestinal canal, and so overcoming one of
the most prominent symptoms of the inflammatory disease—constipa-
tion ; and likewise, by such clearance, favouring the action of other
medicines. Before bleeding, large doses will be necessary, perhaps in-
effectual ; after loss of blood, a much Aveaker purge will obtain the end
desired. They deplete, by causing an increase of mucous exhalation
from the lining membrane of the boAvels; and so assist the direct ab-
straction of blood from the system. They may sometimes exert a de-
rivant effect in favour of the part inflamed, by bringing an unusual
amount of blood to the intestinal canal. They are further of use by op-
posing assimilation, and thereby cutting off the nutritious supply from
the circulation ; thus tending to maintain the wished-for depression of the
system. During the decline of action, they are still of use—if not con-
tra-indicated by general debility—by favouring absorption in general,
and consequently the disappearance by absorption of the fluid effusion
in the part—particularly the serous, inasmuch as it is that portion of
the blood which they tend to diminish.
They are especially of service in affections of the head, having a
marked derivant effect on the brain, as Avell as on the upper parts of
the body in general; the pallor of the countenance which follows purga-
tion is familiar to all; as also the lightness and giddiness of the head,
which are apt to ensue by continuance of its use. On the other hand,
there are cases in which they cannot prove but injurious; as in com-
pound and comminuted fractures, where total absence of motion is by
far the most important part of the treatment; and in inflammatory af-
fections of the bowels themselves—Avhen, by effecting both increased
determination of blood and exaltation of the organ's labour, they could
not fail to injure grievously.
Purgatives are at first usually of a drastic and searching nature, after-
wards simple and saline ; their object being first to evacuate thoroughly,
as Avell as to promote copious secretion, more especially from the liver;
afterwards merely to keep up a moderate exhalation from the mucous
membrane. If need be, they may be occasionally assisted by enemata;
or these may even sometimes occupy their place, Avhen the stomach
proves especially resentful of intrusion.
4. In some cases, emetics are useful, at the outset; clearing the sto-
mach, encouraging secretion from the liver, interrupting assimilation,
and favouring perspiration; also, as auxiliaries to expectoration they
may prove highly advantageous. This class of remedies are of ccu-se
inexpedient, when there already exists marked determination of blood
10*
114
PRINCIPLES OF SURGERY.
to the head : the effort of vomiting would be very dangerous. On the
other hand, they may be expected to prove especially beneficial, in
those inflammations which are preceded and accompained by obvious
biliary and stomachic derangement; in most cases of erysipelas, for ex-
ample, there is no better commencement of the treatment than full and
free emesis.
5. Mercury.—The mercurial is often the preferable form of purge at
the outset of treatment—calomel, followed by jalap, for example ; caus-
ing copious exhalation from the intestinal mucous membrane, promoting
a free Aoav of bile, and—if that secretion be part of the fuel by Avhose
intra-combustion animal heat is maintained, as chemistry has of late
hinted—obviously tending to loAver the febrile increase of temperature.
But it is not as a purgative that mercury is chiefly antiphlogistic ; not
when it passes quickly through, but when it is retained" in the prima?
viae, absorbed thence into the system, and lays hold of this, exerting
on it a specific effect; the systemic seizure being usually indicated by
fcetor of the breath, tenderness of the gums, and rawness, of the mouth,
which, if the introduction of the mineral be continued, advances to
complete salivation. But as it Avas not the purgation, so is it not the
salivation AYhich we usually desire. Mercury, gradually introduced
into the system, seems to exert a tonic effect on both the extreme blood-
vessels and the lymphatics, that is on the exhalants and-the absorbents;
thus preventing or limiting impending effusion, and at the same time
expediting the removal of that which has been already exuded. The
affection of the gums is not of itself valuable, but only as showing that
the impregnation of the system by the mineral is so far advanced, as to
be equal to the effecting of this result—truly antiphlogistic. Besides,
mercury is supposed to act directly on the blood, affecting the red cor-
puscles, as well as assisting in removal of the anormal proportion
of its fibrin.
From its power of at once limiting and removing effusion, it is very
plain how valuable must be its administration in all inflammatory affec-
tions of important internal organs, Avhose functions must seriously suffer
by any considerable change of structure, however temporary ; or Avhen
texture is extremely delicate—even slight effusion producing much dis-
order, and hard to be recovered from—as in the iris, and synovial
membrane. When such parts are becoming truly inflamed Ave give
mercury with much eagerness, desirous that its constitutional effect
should be both speedy and complete. But he is a sadly thoughtless
and reprehensible practitioner Avho throAvs in mercury with a loose hand
and a careless eye for inflammations in general—real or supposed—re-
gardless of the risk thereby encountered of hopeless ruin to the system
at no very distant date, by the remote consequences of wanton and un-
called-for mercurialism. It is fortunate for us that such risk need not
be dreaded by the wary surgeon, who not only gives no mercurial
course unless such be demanded, but also inquires diligently into the
circumstances connected with that demand, ere he admits it to be just
and true. When satisfied on this point, he hesitates no longer; but
proceeds to his duty of saving vitally important texture and function at
all hazards, comforted by a belief, well grounded on experience, that,
ON INFLAMMATION.
115
by such inflammations there is engendered a tolerance of mercury, both
present and future.
The best form of exhibition is calomel, usually combined with opium,
in the form of pill; tAVO grains of the former, with half a grain of the
latter, repeated every hour or every tAvo hours, according to the haste
with Avhich Ave desire to affect the system. The opium prevents the
mercury being Avasted as a purge, and insures its internal reception by
absorption, while itself has a beneficially sedative result on both the
nervous and vascular systems. It has lately been proposed—in accord-
ance Avith a laudable desire to obtain the constitutional effect at the
least possible cost of mercury—to give calomel in Arery minute doses,
often repeated ; as the tAvelfth of a grain every hour; absorption being
supposed to take place very readily and fully from minute doses—as is
exemplified in the internal use of arsenic. Such caution is much to he
commended, and such doses are highly alloAvable, in cases of no great
urgency, either as to intensity of action or importance of texture in-
volved ; but the old experienced dose, as above stated, is far more
trust-Avorthy in the true inflammatory emergency. Should calomel and
opium be found to disagree, a convenient substitute may be found in
the hydrargyrum cum creta with Dover's poAvder. When it is desi-
rable to affect the system with extreme rapidity, or when the ordinary
mode of exhibition is peculiarly tardy, the desired result may be acce-
lerated by rubbing in a mercurial ointment or liniment on the intside of
the thighs, in the axillae, or over the part affected.
Mercury, hoAvever, let it ever be remembered, is only subsidiary and
second to bleeding a,s an antiphlogistic. The intensity of the vascular
action must be first broken by loss of blood ; the remainder is then Avell
dealt with by the mercury. But should the latter go single-handed to
the contest, it is sure to fail; harm is done instead of good ; the inflam-
mation and its accompanying fever are both augmented, as can be
readily understood, Avhen it is borne in mind that the direct effect of
the medicine is stimulant or tonic to the capillaries.
The time, then, at Avhich Ave are to commence the exhibition of mer-
cury for antiphlogistic purposes is after blood-letting; we desist when
the gums haAre been " touched," as the ordinary phrase is, showing
the attainment to systemic seizure ; or Ave may often cease from its use
at a still earlier period, the sj^mptoms which demanded it having satis-
factorily given way. Should the disease, on the contrary, prove obsti-
nate, even after ptyalism has been induced, the mercury may be cau-
tiously resumed, so as to maintain this until recedence or change in the
symptoms occur; but in no case of mere inflammation is full, far less
sustained, salivation at all necessary.
In all cases, before enjoying its administration, it is well to inquire
as to the existence or not of idiosyncrasy regarding it; whether the pa-
tient is easily affected, or otherwise ; Avhether liable to the troublesome
eczema, or to the dangerous erethismus.
Should mercury both gripe and threaten to purge, notwithstanding
combination with opium or hyoscyamus, it is well that the doses be
given in some bulky vehicle. In non-inflammatory cases—as cer-
tain forms of the venereal disease—such disagreeable tendencies are
116
PRINCIPLES OF SURGERY.
readily avoided by giving the mercury immediately after the ordinary
meals.
Locally, mercury is of use, in the form of plaster or ointment, applied
to the part affected ; but the proper time for its employment is still later
than that of the internal exhibition. It is meet to oppose, not the ac-
tion itself, but rather its results on texture. All acuteness of action
must have been previously subdued by the earlier and more appro-
priate remedies ; and then mercurial inunction, by its tonic and stimu-
lant effect on blood-vessels and absorbents, may hapily restore the
tone of the former, as yet dilated and Aveak, and prone to continuance
of effusion ; Avhile it rouses the absorbents to an increased duty, that
effusion may be removed, and normal condition of texture restored.
But at an earlier period, the same application, noAV so beneficial, could
not fail, by stimulating the blood-vessels, to aggravate the action and
the changes of structure to Avhich it tends.
6. Opium we have already seen to be of use combined with mer-
cury, as an auxiliary towards the constitutional effect of the latter
remedy, by preventing purging. Its own direct influence is also fa-
vourable. But, like mercury, it must folloAV bleeding. Given before
loss of blood, it still further dries up general secretion, seems to increase
the vascular excitement, and aggravates the inflammatory symptoms,
both general and local—especially the former; not unfrequently in-
ducing alarming delirium. Whereas, folloAving blood-letting, the se-
dative effect on the circulation which this had induced is maintained,
the general nervous system is soothed, pain in the inflamed part is
assuaged ; and, with the combination of mercury, ipecacuanha, or an-
timony, secretion is not opposed. The patient, previously tossed on a
sleepless couch, sinks into a profound and SAveet slumber, and awakes
refreshed; with a soft moist skin, and with this troubles, both local and
general, wondrously abated. After severe bleeding, Ave have already
seen how a full opiate is of much service in allaying or altogether pre-
venting nervous reaction; but, Avhen much blood has been lost, the
dose of opium, although full, should ahvays be very guarded ; soothing
is wished, not thorough narcotism ; yet, under such circumstances, the
latter is not unlikely to be induced, directly perilling existence, should
the opiate be imprudently repeated at too short intervals. Narcotism
may be also untowardly encountered, by repose in a common belief
which we humbly conceive to be an error ; viz., that Avhen opium is to
be given by the rectum, a much larger dose is necessary than when it
is administered by the mouth. The dose should be the same ; cer-
tainly not greater. Its absorption by the mucous membrane of the
lower bowel is just as likely to be speedy and full, as that by the sto-
mach ; perhaps more so, seeing that, as Dupuytren has observed, the
function of digestion may interfere obstructingly in the one case, but
cannot in the other. I, of course, assume that the lower bowel is free
from accumulation, and that the fluid opiate is brought into direct and
general contract with the lining membrane. With due precaution,
however, the administration of opium by the rectum is a valuable sub-
stitute for its ordinary mode of exhibition, when there happens to be
much nausea, the stomach rejecting all ingesta.
ON INFLAMMATION.
117
During inflammation of internal parts, attended with excruciating
pain—as in peritonitis—opium must be given in larger doses than
usual, and oftener-repeated ; for not only is there a tolerance of the
remedy created by the disease, but such pain must be subdued at all
hazards, othenvise it will inevitably exhaust the poAvers of life. Still,
hoAvever, the opium must folloAV bleeding, not precede it. In such
cases it may be given pure, the anodyne effect being the paramount in-
dication. But,, for ordinary antiphlogistic purposes, it is combined Avith
mercury, antimony, or other auxiliaries; and thus is avoided the dis-
advantageous tendency, Avhich it is otherwise apt to evince, of op-
posing secretion.
In inflammatory affections of the brain or its envelopes, or when these
important parts threaten to become secondarily involved, opium must
be either abstained from, or given cautiously in combination; for it
tends to induce determination of blood to the head. If altogether dis-
used, its place may be occupied by conium, Avhich has a directly oppo-
site—derivant—effect in regard to the cranial contents. If employed,
let it be combined Avith antimony, given watchfully, Avith the head Avell
raised and kept cool. Such antimonial combination is extremely use-
ful in all cases of cerebral excitement, which Ave are very anxious to
subdue, and against Avhich we are afraid to employ opium, alone and
unmodified in its effects.*
7. Antimony is a valuable antiphlogistic ; usually given in the form
of tartrate. Its effect varies according to the amount of dose. An
aqueous solution, containing .a sixth of a grain, repeated every tAvo
hours, will produce diaphoresis; thereby overcoming the arid state of
the skin, relieving the capillaries by restored secretion, and undoing
one of the most characteristic sj^mptoms of inflammatory fever. And if
diaphoresis be especially desired, its occurrence may be greatly facili-
tated by the hot bath, partial or general. A quarter of a grain simi-
larly administered, not only proves diaphoretic, but occasions nausea,
and exerts a sedative influence on the general circulation ; and that in-
dependently of previous loss of blood. Of course it will prove a more
poAverfully depressing agent when blood-letting has been premised ; but
it is important to bear in mind that such precedence is not necessary to
its antiphlogistic effect, as in the case of mercury and opium—for from
the first it seems to diminish the tonicity of the vascular system; and,
consequently, in many inflammations, neither themselves very intense
nor seated in important parts, antimony single-handed may effect the
desired depression, leaving the veins unimpoverished of their all-im-
portant contents. In the dose of from half a grain to a grain, repeated
every tAvo hours, besides the ordinary effects of the medicine—sedative
and diaphoretic—a still more truly antiphlogistic influence, someAvhat
resembling the mercurial, is said to be exerted ; opposed to general ex-
aggeration of arterial tone, favourable to absorption, and so tending to
* R.—Tart, antimonii, gr. ii.—gr. iv.
Tinct. opii,-3i.—3ii.
Aquae fervidae, §viii. *l.
Sig.—A table-spoonful every two hours.—Graves.
118
PRINCIPLES OF SURGERY.
restore normal texture and function ; and this last effect is farther said
to be most distinctly shown in inflammation of vascular internal organs.
It may be supposed that thus employed, antimony is only a duplicate
of mercury. But it is not so ; the effects of calomel—more especially
when sakelessly given—are insidious, protracted, and bode evil for the
future ; those of antimony are only temporary. When, therefore, a case
occurs in which either medicine may seem to be equally able to relievo
the part efficiently, antimony is decidedly preferable ; in such circum-
stances it is the superior of mercury, not its mere equivalent—giving
similar benefit from its use, yet leaving no lurking danger behind.
Again, both may be advisable remedies for one disease ; each em-
ployed at its own appropriate period of the case. Thus in pneumonia,
full doses of antimony are most likely to relieve in the early stage,
while effusion is still soft, recent, and of more or less fluid consistence;
while at an advanced period, hepatization being completed, greater re-
liance may be placed in the effect of mercury, if the constitutional symp-
toms have subsided. For this seems not only to favour absorption of
recent and fluid deposit, but to be capable of undoing that which is of
older date, and some way advanced in organization ; softening it, and
so fitting it to become the prey either of absorption or of ulceration.
In this country, the doses of antimony are seldom made higher than
those already specified; but on the Continent, ten grains and more,
repeated, are not unfrequently indulged in. But it remains yet to be
shown whether such heroic measures are in any respects superior,
and not in many inferior, to the ordinary mode and amount of admi-
nistration.
It is to be remembered that a certain tolerance of the remedy is
doubtless engendered by the inflammatory process; and consequently
the patient is to be warned that though the first dose or two may in-
duce nausea and even full vomiting, he is not to be discouraged thereby,
but to persevere, as the sickness will soon and certainly cease. When
tolerance is suspected to be incomplete, hoivever, or when it is espe-
cially desirable that no actual emesis should occur, a few drops of
laudanum, or of the solution of the muriate of morphia, may be given
with each of the two or three first doses of the antimony ; or these may
be combined Avith from five to ten drops of the dilute hydrocyanic acid.
The happy effects of a combination of antimony Avith opium, in cases
of disorder of the cerebral functions, without inflammation within
the cranium, yet with a suspected tendency thereto, have been already
noticed.
8. Aconite and Belladonna, in addition to their anodyne properties,
exert a directly sedative influence on the general circulation, and may
consequently prove useful in this respect as antiphlogistics ; the former,
especially, shows great power in lowering and softening the pulse.
Both, hoAvever, must be given in small doses, and Avith caution, lest a
too great depression of the vital powers ensue. Their use has lately
been much extolled, in the inflammatory stage of erysipelas ; and the
former has for some time enjoyed considerable reputation as a success-
ful opponent of rheumatic affections of an inflammatory nature.
9. Colchicum, also inducing a sedative effect on the circulation and
ON INFLAMMATION. 119
tending to cause increased exhalation from the mucous membrane of
the'bowels, as well as very marked increase of secretion from both the
liver and the kidneys, is plainly qualified to prove highly available as
an antiphlogistic. In full doses, continued, it is supposed to exert a
specific effect on the part, freeing it from impending change of struc-
ture, as do mercury and anatomy. Being farther^ endowed with the
property of eliminating urea from the system, by its agency on the kid-
neys, it is especially appropriate to inflammatory affections of a rheu-
matic origin and character. The Avine of the seeds, cautiously com-
menced and steadily increased, is the favourite form of the remedy.
Diuretics in general, by their evacuant effect, may be classed among
the not unimportant antiphlogistics; especially their simplest forms ;
nitrate of potass; bitartrate of potass, SAveet spirits of nitre, acid and
alkaline drinks, &c. They of course are exceptionable, ivhen the se-
creting organ, the kidney, happens to be the seat of the inflammatory
disorder ; for by their use under such circumstances, the paramount in-
dication of obtaining rest, actual or comparative, for the affected part,
would be most palpably contravened.
10. The antiphlogistic regimen is not the least essential part of the
treatment. It comprehends 1.—Diet. This is obviously to be given
but sparingly, and invariably of a non-nutritious character, so long as
the action remains unbroken ; and even then the return to more gene-
rous food must be most gradual and cautious. Fortunately, loss of
appetite and loathing of food are usually tolerably prominent during the
inflammatory progress ; it is during the period of its decline that pre-
caution is necessary, in denying the returning appetite, or deceiving it
by unproductive materials. A hearty meal, untimeously indulged in, has
often reinduced all the mischief. Drink should be bland, simple, and
cooling; given often and in small quantities, rather than in copious
draughts ; for the latter, unless productive of diaphoresis or diuresis,
are apt to injure by tending to plethora. Thirst, hoAvever, is usually a
most troublesome symptom of the inflammatory fever, and must be as-
suaged, with due precaution. Acidulous drinks are usually the most
refreshing; and of these it is well to have some variety, as the most
palatable is apt to become distasteful after a time. Diluted solutions
of nitrate of potass, and of the alkalies combined with vegetable acids,
are not only grateful to the parched mouth, but likewise relieve the
fevered system by favouring secretion—therefore not unjustly termed
Refrigerants. 2.—Rest of the body, with quietude of mind, is plainly
an important indication, and ought to be fulfilled so far as circumstances
will permit. Restlessness and jactitation are symptoms of the consti-
tutional disorder, as also tendency to apprehension, anxiety, and general
disquietude of mind, and consequently to a certain extent inevitable.
The general antiphlogistic management, by removing their cause, is
the most effectual means of removing them ; but some time is necessary
for this ; and in the meanwhile much may be done by many little atten-
tions on the part of the attendants. 3.—Air. When it is remembered
how essential is a free supply of good air to the maintenance of a
healthy state of the blood, and how imperfect aeration leads to obstruc-
tion of the capillaries, systemic as well as pulmonary, the necessity for
120
PRINCIPLES OF SURGERY.
due ventilation of the sick-chamber becomes very apparent, during the
progress of inflammatory disorder—a process so intimately concerned
with capillaries and their contents.
Local Treatment.—1. Rest. To procure as complete rest of the in-
flaming part as circumstances will possibly permit, should be the first
care of the surgeon ; and to maintain it undisturbed, his efforts should
be directed throughout the Avhole period of treatment. Availing him-
self of an important advantage which he has over the physician;
namely, that in surgical inflammations of external parts, this valuable
indication may be often fulfilled, Avhile it can only be effected partially,
if at all, in the case of an internal organ—as the head, lungs, or kid-
ney. Place an inflaming joint in a state of rest, so soon as you are
called, and maintain its immunity from motion undisturbed, by splints
or othenvise, and you will not require to take largely from the rest of
the antiphlogistic catalogue; Avhereas permit its play, voluntary and
involuntary, to remain uncontrolled, and leeches, cuppings, blisters,
time, may be all freely expended, Avithout securing an equally satisfac-
tory result. And the same parallel may be draAvn in regard to every
part truly inflamed.
2. Position.-.—Not only should the part be put and kept at rest, but
it should also be placed and maintained in such a position as to favour
the antiphlogistic result. The knee, for instance, is bent, so as to relaz
the muscles implicated, thereby relieving tension and diminishing the
risk of involuntary spasmodic movement; Avhile the limb is also ele-
vated, in order to favour venous return, and retard the arterial influx.
The inflaming part having been thus attended to, as regards both rest
and posture, Ave are in a favourable position for proceeding to local
blood-letting, in the manner and on the principles already detailed.
3. Cold.—With some it is still an unsettled point Avhether heat or
cold be the preferable application to an inflamed part; the question
being usually left open, to be determined either by chance or by the
feelings of the patient. I believe heat and cold to be both valuable
antiphlogistics, but that each has its appropriate period for use, and
that either employed out of its own proper time and place will inva-
riably do harm. The virtue of cold is chiefly as a prophylactic, dili-
gently and carefully employed during the period of incubation. Thus,
after the infliction of an incised Avound, Ave are anxious to prevent in-
flammation, or at least to retard and limit its occurrence, and have re-
course with this vieAv to the continued application of cold in the manner
formerly described. Should Ave succeed in averting the inflammatory
process altogether, Ave gradually cease from the application. And
should the inflammatory process fairly set in, notwithstanding our
efforts to the contrary, I consider it to be equally our duty to desist;
the time appropriate for cold has passed, and if its use be persevered
in, harm will folloAv. For it then opposes exudation, and so prevents
the natural relief of the over-burdened vessels ; it promotes contraction
of the parenchyma, rendering this less yielding, than it would other-
wise be, to the* effusion Avhich does occur, and so favours tension and
consequent aggravation ; and during the farther progress of the action
fc must, by-its directly sedative influence, depress the vital power of
ON INFLAMMATION.
121
the part—so favouring the supremacy of action over power, and hurry-
ing on the former to its extreme results, of suppuration, ulceration, and
gangrene. During the rise of the inflammatory process, it may induce,
or seem to induce, abatement of one symptom—the heat; but in all
other respects the part will sustain injury by its use. During incuba-
tion, be diligent in its application, but desist so soon as the signs of
inflammatory accession have become apparent.
Another precaution is necessary. Let not the sessation be abrupt,
but gradual; from cold to cool, from cool to tepid, from tepid to Avarm,
from Avarm to hot; othenvise the second or reactive effect of cold, in-
tensely favourable to vascular action, is inevitably produced. During
the use of cold, it is its first or sedative effect which we desire to main-
tain ; while departing from this, its fitting time having elapsed, we
should beAvare of inducing the second, Avhich may of itself originate
perverted vascular action, and is certain to accelerate its advance if
already begun—more especially should the power of the part happen
to be even temporarily depressed.
When action has fully subsided, and effusion, too, has greatly dis-
appeared, the part still, hoivever, remaining weak, lax, and swoln,
with its blood-vessels in a congested condition, cold again may become
serviceable; but not intense—othenvise poAver might be still farther
reduced—and accompanied by a mechanical influence, as in the form
of douche ; producing a general astringent effect on the part, someAvhat
stimulating the absorbents, and imparting tone to both blood-vessels
and parenchyma. Cold thus is found to be of use at both extremes of
the inflammatory process—just before its accession, and subsequenly
to thorough recession ; but during the actual existence of the action, it
is inapplicable.
4. Heat and Moisture, plainly less suitable than continuous cold
during incubation, are as plainly preferable during the inflammatory
process. They are grateful to the feelings of the patient, allaying the
sensations of pain, heat, and tightness. They favour effusion from the
vessels, Avhereby natural relief is given to the oppressed local circula-
tion ; they, at the same time, relax and promote the yielding of the
parenchyma, to receive accommodatingly this copious exudation; not
only are the vessels relieAred, but the texture is not incommoded ; there
is no tension, and consequently, no increase of throbbing and pain,
with aggravation of the disorder. Also, by relaxation of both blood-
vessels and parenchyma, combined Avith relief of the former by exuda-
tion, the stagnating tendency of the blood is opposed, and renewal of
the circulation favoured. It is very obvious hoAV thus heat and moist-
ure tend to a favourable result during the crescent process, but it is
equally clear that, at a subsequent period, during the decline, their use
cannot be continued Avithout disadvantage; for the acute aption over,
and its results remaining, that which tends to continue effusion, to pro-
Ion^ the dilated condition of the vesels and relaxation of the surround-
ing"parts, is opposed to resolution, and positively injurious. Let the
application, then, be diligently employed during the active stage, and
gradually abstained from so soon as the process of decline has been
fairly established. There is little doubt that protracted chronic action,
122
PRINCIPLES OF SURGERY.
with tedious suppuration, is often attributable solely to injudicious con-
tinuance of poultices and fomentation.
The form of application may be either that of cpifhem or fomenta-
tion. The latter is more generally available. A piece of flannel, or
sponge, wrung out of hot Avater, is applied, as Avarin as can be conve-
niently borne, and replaced by a substitute so soon as the heat begins
sensibly to abate. This is continued for half an hour, or more, and
repeated at longer or shorter intervals, as circumstances may seem to
demand ; the part being in the meaiiAvhile softly dried, and covered
either by a poultice or by. some dry simple investment—as a piece of
linen, wadding, or soft flannel. It is well sometimes to medicate the
fomentation ; chamomile floAvers, with heads, of poppy, for instance,
may be put into a flannel bag, and used instead of the common flannel
or sponge. The patient will be inclined to place more faith in such a
fotus than in mere hot Avater, and, besides, positive benefit is also de-
rivable from the anodyne qualities of the medication. When the per-
verted vascular action is on the surface, and attended with much jain
and increase of sensibility, the warmth and moisture may be still far-
ther medicated ; thus, in some forms of erythema, and especially in
inflammatory affection of the superficial lymphatics, much relief is ob-
tained by keeping the part constantly moistened with a solution of
acetate of lead and opium, in the proportion of two grains of each to
the ounce of Avater; a sedative and anodyne effect is thus superadded
to the ordinary tendency of fomentation. The foim of epithem is some-
times inapplicable, the part being Avholly intolerant of weight and pres-
sure, as in acute affections of the eye. But Avhen moderate weight is not
objectionable, and the continued application of heat and moisture is
. desired, the ordinary poultice is very suitable in many cases; made
light, soft, free from grease and all irritants, actual or possible; and
reneAved as often as maintenance of sufficient temperature requires.
Nothing is better, for example, in an inflaming ulcer, a forming boil or
abscess, or a sloughing bruise. But there are many cases, on the
other hand, in which it may be well superseded by a more elegant and
convenient substitute—lint, folded double, or quadruple, dipped in
warm water, laid on the part, and covered by a larger piece of oiled
silk, Avhich retains the heat and moisture, and prevents soiling of bed
and body linen. In ordinary inflaming wounds and ulcers, for exam-
ple, this is infinitely the preferable form of application; more easily ob-
tained and renewed, less odorous, less heavy and cumbrous, less apt
to irritate by degeneration, than the common poultice. Or a third form
of application may be employed—steam, as recommended by Dr.
Macartney. It may be applied by means of an ordinary vessel; or
what is better, an apparatus such as recommended by the doctor, may
be employed. A lamp, acting on a small tin vessel, filled with water,
generates steam ; and this is conveyed directly to the part through a
woollen hose, twelve inches in diameter, kept open by elastic hoops,
and about three feet in length to prevent scalding. Perhaps the only
objection to this form is, that the suitable means and appliances may
often not be at hand, while hot water and flannel, for ordinary fomen-
tation, can always be obtained, even on short notice.
OF INFLAMMATION.
123
5. Nitrate of Silver has two modes of action, according to the severity
of its application. 1. When passed lightly, in the solid form, over the
part previously moistened, the surface, if subsequently exposed to
atmospheric influence, becomes black, dry, and hardened; or the same
result may be obtained by the use of a strong solution. At the same
time, a mitigation of all the ordinary symptoms of the inflammatory
process is almost invariably evinced, if the action be neither very active
nor advanced, and situated not deeper than the cutis vera. In simple
erythema of the fingers, for instance, often nothing more is requisite,
except local rest and constitutional care, to achieve speedy and satis-
factory resolution. The effect is plainly sedative and antiphlogistic,
acting directly on the part; but the modus operandi seems to be as yet
shrouded in mystery. The blackened and otherwise altered epidermis,
doubtless, affords an additional and very effective protection to the
tender dermis, from atmospheric influence and other external stimuli,
and thus one important benefit is obtained ; the rest we cannot trace ;
yet Ave are not the less glad to avail ourselves of the fact, undoubted,
though but imperfectly accounted for, that nitrate of silver, thus lightly
used, has a purely antiphlogistic effeet on inflammatory affections of a
slight and superficial kind.
Iodine, in solution, pencilled frequently on the part, exerts a some-
what similar influence ; but, on the whole, it is probably inferior to the
nitrate of silver as a direct local antiphlogistic, although it may be,
under some circumstances, a very convenient substitute. In red, pain-
ful sivellings of the toes, for instance, often associated with irritable
corns, and in similar affections of the skin at the roots of the finger
nails, so common in Avasher-Avomen—the external use of iodine seldom
leaves any thing to be desired.
The light use of nitrate of silver may be also rendered available in
circumscribing perverted vascular action, Avhen superficial and disposed
to spread—as in erythema and simple erysipelas. It is applied in sub-
stance to the sound skin, about tAvo inches from the erythematous border,
so as to form a belt surrounding the extending redness on all sides, and
about an inch in breadth. In very many cases—other suitable repressing
means being of course not neglected—the action advances up to this
line of circumvallation, and fails to surmount it; thus becoming arrested
within its confines. Care must be taken, hoAvever, not to produce vesi-
cation by too severe an application, othenvise the effeet will probably
be to hurry on the spread of the redness, and favour its transgression
of the limits Avhich were intended to fix its arrest.
2. Nitrate of silver may be applied firmly and long enough to produce
vesication; an excellent means of counter-irritation, to be immediately
considered; but plainly inapplicable to affections of the very surface,
as to them it must prove a direet rather than a counter-irritant. The
milder form of application cannot be employed too immediately as
regards both time and space—indeed, the earlier and more direct its
use, the more likely it is to prove successful—its effect being directly
sedative and antiphlogistic ; the higher dose, however, effects a plainly
contrary result, as the occurrence of vesication abundantly testifies.
124 PRINCIPLES OF SURGERY.
6. Pressure, like cold, is to be considered rather as a prophylactic,
than as a curative agent in inflammatory affections ; if employed early
and carefully—yet even then the result is problematical, it is quite
possible that very gentle, accurate, and uniform pressure may be made
on a part about to be inflamed, so as to prevent the first step of the
process—determination of blood ; or even Avhen that has occurred to
prevent the second—dilatation and distention of the capillaries; and
that thus the establishment of the process may be, as it were, mechani-
cally obstructed. But I confess that it is much more easy for me to
imagine, that the pressure is not so skilfully and successfully conducted;
that determination to and subsequent distention of the capillaries do
take place, at least in part; that the inflammatory process does begin,
prophylaxis having failed to be complete ; and that continuance of the
pressure then can only occasion evil, by creating much tension, and so
greatly aggravating the disorder.
During the progress of the true inflammatory process, the use of
pressure, however uniformly applied, must prove even more injurious
than that of cold applications, and for similar reasons.
The time for the right employment of pressure is after declension of
the action ; change of structure only remaining, by reason of resolution
, being as yet incomplete. Then it is one of our most valued and efficient
means of stimulating the absorbents, and so removing effusion ; yet
even then its use must be at first cautious, lest it should over-stimulate
the blood-vessels as well, and induce an inflammatory reaccession. It
is applied by means of plaster, splints, or simple bandaging.
7. Counter-irritation, likeAvise, is not to be employed, until all acute
action has fully subsided. During advance of the inflammatory process,
as yet unbroken by the suitable means, the induction of a new action
by a neAV stimulus, even at some distance, not only fails to afford relief,
but usually aggravates both the local and general disorder. The ques-
tion of time, therefore, is an important consideration ; counter-irritation
being the opponent not of acute but of chronic action, and useful in getting
rid of the results of either. Site also is important. Applied to the part
itself, acute action is induced therein ; an occurrence invariably unto-
Avard, unless Avhen Ave Avish for either destruction or thorough change of
structure. And a somewhat similar result is likely to ensue, if the ap-
plication be made in the immediate vicinity of the part affected. To
be beneficial, and even safe, the action artificially induced must be at
some distance from the site of the original disorder; and yet not too far
removed, othenvise the derivant effect it is intended to produce may
fail to operate sufficiently in the right quarter. There is no more valua-
ble remedial agent than counter-irritation ; none more frequently em-
ployed Avith the best results ; but it must be rightly placed and timed;
not too soon, nor too near, nor yet too far aAvay.
Remembering Avhat was formerly stated in regard to metastasis, we
can readily understand the mode whereby counter-irritation acts bene-
ficially on an inflaming part. The effect of the new action is to remove,
or at least diminish, the old. Marked derivation is produced. Blood
passes from the original to the recent quarter of excitement and deter-
ON INFLAMMATION.
125
initiation ; the skin, comparatively unimportant, undergoes a slight and
manageable amount of the inflammatory process; the deep part, com-
paratively important, is thereby relieved more or less effectually from
what endangered both texture and function. The relief is analogous
to that of local blood-letting; less powerful at the time, but by
continuance ultimately more effectual ; not directly sedative to the
system, as Avell as to the part, as is blood-letting, and therefore capable
of being continued Avith all propriety; both remedies take blood from
the seat of inflammation, but by the latter means spoliation of the system
attends on derivation from the part; by the higher grades of counter-
irritation a certain loss is also sustained in the form of serum, liquor
sanguinis, or pus, but that is comparatively trifling, and capable of
being borne with impunity. It must ever be remembered, however,
that induction of the external and derivant action is likely to prove
directly irritant to the system—more especially if that be peculiarly
susceptible of impression by reason of an irritable habit—during per-
sistence of acute inflammatory fever ; as Avell as directly irritant to the
part, during the existence of acute local inflammation. For, in the
former case, the febrile disorder receives a fresh exciting cause, and
obeys it; in the second, the inflammation being yet unbroken in the
part, its stagnant and sluggish blood cannot be roused to effective
derivation—its own circulation must first be restored to freedom—and
the part is not bettered, but the contrary, by having to sustain two
coexistent inflammatory processes, at but a little distance apart, not
unlikely to unite their forces, and conjointly to tend further toAvards
evil.
Counter-irritation may be varied in grade, form, and mode of appli-
cation. 1: Rubefacients, constitute the slightest class, and are simple
counter-irritants. They induce hyperaemia in an external part, and are
of use to relieve a someAvhat similar condition elseAvhere ; they bring
blood to the surface, but do not thence discharge it; it still remains
within the general circulation. Moderate heat, mustard, and various
stimulating embrocations, may be noticed as familiar examples. Of
these, the mustard is probably the most frequently employed; in the
form of epithem, termed a sinapism, or mustard poultice ; made by
spreading, within the folds of fine flannel or muslin, a thick layer of
mustard flour, beat up into a pasty consistence Avith vinegar,* and
moistened and warmed before application. It is kept on until redness
is fully established in the skin ; and for this purpose no definite period
can be assigned, as there are many individual peculiarities in this
respect; some patients retaining such applications for several hours,
with comparative impunity, Avhile others are almost wholly intolerant of
them, by reason of their proving acutely irritant both'locally and gene-
rally. In children, the time of their application should be invariably
brief; as they are not only apt to vesicate, proving more than mere
counter-irritants; but likewise not unlikely to induce even gangrene,
* The chemist says that vinegar is no good solvent of the active principle of the
mustard j but experience assures us that it makes a most efficient sinapism.
11*
126
PRINCIPLES OF SURGERY.
when imprudently or negligently employed. The simple counter-irri-
tants are adapted to the milder and less advanced examples of the
inflammatory process ; active congestions, for instance, in the throat
and air-passages, often yield readily to such measures, when preceded
by leeching and other antiphlogistics. Or the antiphlogistics may be
with safety omitted, Avhen the process is just only begun ; no remora
of the local circulation being as yet even indicated, the derivant effect
may be instant and complete, at once relieving the threatened texture.
Now a few sore throats are daily aborted by the common sinapism,
assisted perhaps only by a purge, a SAveat, and temporary starvation.
As a general rule, however, it is not the less to be inculcated—in
regard to the higher grades of the process, and most especially in regard
to true inflammation-—that even the simplest class of counter-irritants
are not to be employed until a comparatively late period, when all
activity of morbid action has been fairly subdued by other and more
suitable means. Nor should they ever be used, without much caution
in either children or adults of a peculiar irritable habit; for in the
latter they are apt to have a constitutional effect, the reverse of anti-
phlogistic ; and in the former it is possible that the cure may prove
worse than the disease.
Dry-cupping may be ranked among the simple counter-irritants ; that
is, the glasses being applied in the ordinary way, but without the use
of the scarificator. Blood is brought to the surface, and there retained,
during the application, and for some time aftenvards; and the effect is
obviously derivant. It possesses one advantage, important in irritable
habits; namely, that the desired result is at once obtained, Avithout
antecedent irritation ; the blood is brought simply to the surface, without
any previous vascular excitement there.
2. Vesicants, both counter-irritate and prove evacuant; not only
bringing blood to the surface, but also discharging thence more or less
of its thinner part, at first purely serous, afterwards resembling the or-
dinary liquor sanguinis. Heat of considerable intensity ; cantharides,
in the various forms of blistering paper, tissue, and liquid; nitrate of
silver rubbed hard on the part, till pain is felt, the roots of the hairs
look blue, and the general colour of the skin begins to change—are
familiar examples. They are a more powerful class than the rubefa-
cients, and consequently adapted to oppose a higher grade of action.
Their efficacy is especially admitted in regard to the final subjugation
of inflammatory affections of the serous and synovial membranes.
Often, under their use, the embers of acute action are quickly ex-
tinguished, and effusion also speedily disappears ; it may be that they
stimulate the absorbents, as well as relieve from all remaining perverted
vascular action ; or it may be that, by fulfilling only the latter indica-
tion, the liberated texture is enabled to resume its normal function, and
so work out its own cure ; or the counter-irritant, by establishing a
brisker circulation in the vicinity of the part, may so expedite disap-
pearance of the effusion, by absorption of the more fluid portion into
the increased venous return. The simple form of the cantharides is
apt to irritate the kidneys, as evinced by strangury, sometimes se-
ON INFLAMMATION.
127
vere. In affections of the genito-urinary system, therefore, more
especially of the secerning glands themselves, we will either prefer
another vesicant, such as the nitrate of silver, or employ the can-
tharides Avith much caution ; giving bland mucilaginous drinks, and
using one of the " telae vesicatorise," rather than the ordinary plaster;
as these profess to avoid this casualty, and often keep their promise.
If very rapid vesication be desired, ammonia in a concentrated form,
or boiling Avater, or a smoothing-iron removed suddenly from boiling
water may be employed; or the part may be covered with alcoholic
fluid, and then set on fire.
3. Pyogenic counter-irritants prove still more highly evacuant, by
establishing from the artificially inflamed surface a more or less copious
discharge of pus—that is, of the most important part of the blood for
nutritive purposes, whether normal or perverted—its liquor sanguinis.
An ordinary blister may be converted into this class ; at first it dis-
charges pure serum; this becomes less in quantity, and of greater con-
sistence, containing a certain amount of fibrin, and gradually dries up,
the part recovering with desquamation; the action having gradually
passed away. But should the action be continued, either by reappli-
cation of the same cause, the blister, or by the use of some other irri-
tant—as tartar emetic, or savine ointment—the serous discharge is suc-
ceeded by a purulent, true inflammation having been reached ; and
such purulent discharge may be maintained, by continuance of the
stimulating dressing. But Avhen we deem it expedient to employ this
higher grade of counter-irritation, it is usually our object to obtain
discharge of pus from the first.
Tartar Emetic, already found so useful at an earlier period of the
disorder, when given internally, now comes to be of service as a local
application ; in the form either of ointment or of strong solution. Pus-
tules form more or less abundantly, usually of large size, and attended
with a great amount of local action. But this mode, though capable
of producing much counter-irritation, has its disadvantages. The pus-
tules do not always appear in the place rubbed," and AYhere they are
wished ; but often at some distance, doing no good, and creating, a
great deal of unnecessary irritation ; in the axilla, for instance, instead
of on the arm or side. They are apt to be scattered over a large ex-
tent of surface, not concentrating the counter-irritant effect, and conse-
quently comparatively inefficient as regards the seat of disease. From
these circumstances, together with a liability of the larger pustular for-
mations to terminate occasionally in gangrene, not very limited, the
counter-irritant local effect of this application is apt to be merged in
the general irritant—an event not atoned for by absorption of the anti-
nionial into the system. In very many cases, therefore, Ave prefer a
more mild and manageable agent. Croton Oil, pure, or diluted with
some simple oil, and coloured to prevent mistake, produces a very
copious eruption of minute pustules, which cluster closely together, and
almost invariably limit themselves to the part rubbed; and its effects
may be varied from mild to grave, according to the intensity and dura-
tion of its use. Nitrate of Silver, too, in addition to its simple anti-
128
PRINCIPLES OF SURGERY.
phlogistic and vesicant effects, may be made of pyogenic virtue, by
rubbing; in the form of ointment, ten grains to the ounce ; pustules fol-
low, of°a manageable and efficient kind—said to be very useful in the
more chronic affections of the synovial apparatus of joints.
A Seton affords a more copious and constant supply of purulent mat-
ter than any of the pustular agents. It consists of a Avound, chiefly
subintegumental, kept open and discharging by the presence of a foreign
body lodged in its track. The integuments are pinched up, and trans-
fixed by a bistoury, or by a broad needle made for the purpose ; to the
eye of the needle, or to the eye of an ordinary probe Avbich is made to
folloAv the Avithdrawal of the bistoury, a ligature is attached ; to the
ligature is connected a skein of silk or cotton, intended to lodge in the
wound ; by the passing of the ligature its lodgement is effected ; and by
securing the ends in a firm knot, it is securely retained. Poultices and
fomentation are applied, during the first few days, until the inflamma-
tory stage has in a great measure passed by, and free suppuration been
established; then tepid water dressing, protected by oiled silk, will
prove a convenient substitute. The foreign body is moved once or
twice a-day, so as to favour cleanliness by preventing lodgement of
discharge, and by irritation to keep up a sufficient action for the dis-
charge's maintenance. If an increased amount of irritation and dis-
charge be desired, the foreign substance may be smeared with some
stimulating ointment, or soaked in some acrid fluid, before replacement
after the cleansing manipulations. But instead of the skein of silk or
cotton it is in general much better to employ a caouthouc tape; which
is to be had,manufactured for this purpose, of various dimensions; by
absorbing no discharge, it greatly favours cleanliness and absence of
unpleasant odour, and besides remains long entire, and does not re-
quire the painful process of renewal; it is moved to a side once or
tAvice a-day,- Aviped and simply replaced. The necessity for discharge,
evacuant and derivant, diminishing, the size of the seton tape is made
proportionally to decrease ; ultimately the last thin shred is altogether
AvithdraAvn, and its bed encouraged to close. Sometimes, in the case
of large setons of old standing, a clump of red, vascular, angry looking
granulations form at one or other extremity of the suppurating track,
giving the patient much annoyance by pain and irritation, and some-
times emitting a considerable quantity of florid blood. They are
readily got rid of, Avithout removing the seton, by the stroke of a knife
or scissors, or by the application of a powerful escharotic, as the po-
tassa fusa.
An Issue may be established either by the knife, or by an escharotic.
In the former case, it differs from the seton in being an open instead of
a subintegumental wound. An incision is made, and to prevent its
healing, and ensure its degeneration into a suppurating sore, a foreign
body, such as a pea, is placed between the margins, and retained by
plaster or bandage ; the foreign matter of course vary in o- in bulk
according to the extent of the Avound and the amount of action Avith eva-
cuation desired. When an escharotic is used, it may be either poten-
tial or actual; the former is the more generally employed; and the po-
ON INFLAMMATION.
129
tassa fusa is on the whole the most suitable. It may be rubbed steadily
on the part, until destruction of texture is effected to the desired ex-
tent ; or a portion is laid upon the part, and retained by plaster, which
at the same time is made to protect the surrounding integument, Avhich
we Avish to leave uninjured; or a slight incision is made, and into that
is inserted a portion of paste composed of equal parts of the potass and
quick lime. In any way, an eschar or slough is formed, it separates
by inflammation and ulceration, and a suppurating sore is exposed on
its detachment. This sore may be kept discharging by stimulating ap-
plications, either constantly or occasionally employed; or it may be
permitted to heal of its own accord, reapplication of the caustic in the
same or another part being subsequently made if necessary. During
the separation of the slough a poultice is applied ; afterwards the Avater
dressing ; if healing is to be opposed, some irritant ointment, of which
there are many in ordinary use, especially the Unguentum Tartratis
Antimonii and the Unguentum Sabinae. When we wish the evacuant
effect chiefly, Ave keep the original issue permanently discharging—as
in many chronic affections of deeply seated soft parts ; Avhen AYe desire
to mingle active counter-irritation with copious evacuation—as in ulce-
ration of the articulating hard tissues—we prefer a succession of eschars,
bringing repeated inflammatory accessions externally as well as main-
taining purulent discharge.
The Actual Cautery stands highest in the list of evacuant counter-
irritants. In former times it Avas in much request by the practical sur-
geon—forming an invariable part of his armamentarium in daily use—
and at the hospital visit uniformly found gloAving in the furnace, ready
for the performance of its accustomed function. But noAv-a-days it is
often supplanted, happily and humanely, by milder and not less effect-
ual means. For haemostatic purposes the ligature takes its place ; for
removal of suspected parts the knife is preferred ; it is seldom applied,
Avith any vieAV, to the hard textures ; in the establishment of caustic
issues in the soft parts, it often and justly gives Avay to its potential
substitute. The heated iron Avas no inappropriate badge of the dark
days of our art; and it might Avell lead to boding despondency in most
of us, to find its indiscriminate and frequent use threatening to return.
Still, on the other hand, let us not shrink from its employment, cruel
and barbarous though it seem, in those cases Avhich we knoAV by ample
experience are to benefit more from that than from any other applica-
tion. I should be very umvilling to depart in any Avay from the axiom,
" Ad extremos morbos, extrema remedia;" I Avould act up to it, and
yet I Avould not exceed it. In advancing destruction of texture in the
bones of joints—more especially if deeply seated—all other means of
counter-irritation should, in the first instance at all events, give place
to the actual cautery ; speedy arrest of such action is our anxious desire
ere the change shall have proved irreparable, and Ave are culpable if
we do not at once employ that remedy which we knoAV to be most
available to that important end. In chronic affection of some of the
internal organs also—the kidneys, for example—a cure may be ob-
tained by the actual cautery, after having been denied to all other
means.
130
PRINCIPLES OF SURGERY.
The cautery may be flat, edged, or globose.
is usually preferred ^-^^^^s^^^f^^ra
for the purpose of
counter-irritation. It
is heated to a Avhite heat, and applied in line3 to the part,
to the extent deemed requisite ; and the manner of such
lines may be varied
according to the
whim or taste of the
nractitioner—so
or so,
or so.
Such lines are equally effectual as counter-irritants, in all probability,
with a broad continuous slough, and on healing leave an infinitely less
formidable cicatrix. The applying hand should be heavy enough to
penetrate through the entire true skin, so as to avoid the very painful
burn which would othenvise result from exposure of the highly sensi-
tive cutis; and it Avas Avith this vieiv that we specified the whiteness of
the hot iron. Yet the hand should not be so heavy as to lead to the
involvement of subcutaneous parts in the separation of the eschar—an
unnecessary and umvarrantable sacrifice of texture. For a feAv hours
after the cauterization, cold is continuously applied, to allay the pain,
which, under any circumstances, is severe; and aftenvards the eschar
is covered Avith a tepid poultice.
It has been advanced by the advocates for an almost indiscriminate
use of the actual cautery, in those cases which require purulent dis-
charge from the surface, that it is doubly advantageous, and therefore
superior to its potential substitute ; in as much as, by the terror which
is imparted to the patient's mind, it achieves a sedative effect on the
system at large, while the pain Avith the coming inflammation and dis-
charge are more directly to relieve the part. But they forget that the
use of an escharotic in any form, for the purpose of counter-irritation,
is only advisable at a comparatively advanced period of the case, Avhen
the expediency of a sedative result to the system is very questionable.
And, besides, I have yet to learn that it is ever part of the surgeon's
duty to strike terror into his victim, iustead of winning his confidence,
and soothing his alarm and fears.
The Moxa, once much in vogue, has latterly fallen into comparative
desuetude. It consists of either a cylindrical or conical roll of porous
substance, adapted for steady and gradual combustion. It may be
made of the down of the artemisia latifolia—the substance originally
employed ; or a very convenient substitute for the Chinese original may
be obtained, in fine cotton wadding, carefully dried after immersion in
a solution of nitrate of potass, and enveloped in tissue paper leaving
the ends free. It is held in the regular porte-moxa, or in the noose of
a common Avire. One end having been placed over or on the part to
be cauterized, the other is set fire to, and the ignition maintained by
either the blow-pipe or bellows. According to the distance at which
the burning mass is held, the effect may be made to vary from simple
redness to actual eschar; and the latter may be in the same Avayrcm-
ON INFLAMMATION.
131
lated, both as to extent and depth. When applied with any degree of
intensity, the pain is great, as can readily be conceived ; nor is the pa-
tient's alarm and apprehension at all trifling. But one advantage cer-
tainly attends its full use ; viz., that after combustion is over, the pain
very rapidly disappears. The part seems to be killed so thoroughly,
throughout the whole thickness of the true skin, that it is incapable of*
further sensation. If desired, the surrounding skin may be protected,
during combustion, by wetted lint; but it seldom altogether escapes
injury, and is usually the seat of tingling pain, by and bye aggravated
by inflammatory accession. The application of cold Avater assists in
the subsidence of pain, immediately after the application. By this
means very efficient and very varied counter-irritation may be effected ;
and it was long considered a very potent remedy in chronic affections
of joints, both of inflammatory and of neuralgic origin. Indeed, it is
not easy to understand hoAV latterly it should have become so much
neglected, unless indeed it be from the not unnatural disinclination,
which most people may be found to possess, to so deliberate and undis-
guised an application of fire to the most sensitive part of their living
frame.
The actual cautery, in Avhatever form applied, is doubtless a very
painful and in all respects severe remedy. In my humble opinion, it
was not only much too frequently and indiscriminately employed long
ago, but in the present day may be found smoking in the hospital Avard
oftener than necessity demands, or expediency Avould Avarrant. The
cases which absolutely require its use are comparatively limited as to
occurrence; and for these, in the name of humanity, common sense,
and propriety, let it be reserved. Also Avhen employing it, in cases
hoAvever suitable, let it be borne in mind, that such an application may
not improbably prove in itself a disease of no mean importance, as re-
gards its influence on both the system and the part; and its effects
ought always to be carefully watched, with this fact in our remem-
brance. For example, it is a good rule in practical surgery, after
having failed with this most poAverful agent to arrest the progess of
destruction in a joint, not at once to proceed to amputation, even
should the hectic seem urgent; but to discontinue the remedy, and
Avait a little ; perhaps the hectic as Avell as the local disorder may hap-
pily decline, a fresh opportunity for other practice may be afforded, and
after all the limb may be saved.
Stimulants and Sorbefacients.—These, being latest of application,
come naturally last in the order of enumeration. Let us suppose that
an intense inflammatory action has been first broken by blood-letting
and other sedatives and evacuants; that its subsequent chronic linger-
in o-s have been effectually overcome by judicious counter-irritation;
the part is then found free from perverted action, chronic as well as
acute, but labouring under no little change of structure, from which it
is unable effectually to clear itself; or, the task seeming onerous, it is,
as it Avere loath to begin. It is then that this last class of remedies
prove highly advantageous; restoring tone to the dilated and Aveak
capillaries, arousing the slumbering circulation to normal vigour, and
stimlating the absorbents to an exaltation of their function; it may be.
132
PRINCIPLES OF SURGERY.
mechanically supporting the part, and preventing return of both con-
gestion and effusion. If the action have been but transient, such ad-
ventitious aid Avill probably not be required ; the part, freed trom action
of a perverted kind, at once resumes its own, of the normal standard;
becomes its OAvn physician ; Avorks its OAvn final cure. But in all cases
♦when action has been continued, inevitably bringing considerable struc-
tural change, not only is such extraneous assistance expedient, but it ia
only by a patient continuance of its use that local health can be regained.
Friction, simple or medicated; plaster, Avith or without bandaging;
mercury, in the form of either epithem or inunction—are the more com-
mon examples of this class of remedies. Their use is invariably to be
deferred, until all action is over ; they are also to be begun cautiously
and continued warily, lest at any time inflammatory accession should
be re-induced. If this be threatened, they should be suspended on
the instant, and not resumed until all again is quiet.
When much fluid effusion remains after cessation of action, as in the
serous cavities, the best sorbefacients, or promoters of absorption, are
those Avhich act upon the system, and evacuate by excretion, especially
purgatives and diuretics, pushed as the system will conveniently bear.
Let it not be forgotten that in all cases of true inflammation, espe-
cially the more severe, the part long—perhaps always—remains weak;
both prone to re-accession of perverted action, and ill able to control
or bear up against it; therefore such a part is to be carefully nursed,
and protected from the more prominent exciting causes; and, Avhen
action has recurred, Ave should anxiously seek for its timeous and
complete arrest.
Now, let it not be supposed, that in each example of inflammation,
of even in most, the Avhole of the items of the foregoing copious cat-
logue of antiphlogistics are to be employed; that Avere to enjoin the
running of a gauntlet, from Avhich very few frames could escape
unbroken. Selections are to be made ; and it is in this practical depart-
ment, that a knowledge of facts triumphs over mere theory—the prac-
titioner tempering and guiding his theoretical knowledge by expe-
rience, judgment, and discretion. It can be readily imagined that no
definite rules can be laid down on this subject; but the following may
be stated in brief illustration. There are very many surgical inflam-
mations—as after-Avounds, bruises, fractures, burns, &c.—in the treat-
ment of which none of the higher antiphlogistics are required: the
internal use of antimony,* action on the boAvels, local blood-letting,
* The following solution will be found highly available for general antiphlogistic
purposes in practical surgery :—
R Tart: antimonii gr. n.
Sulph : mngnesioe 5 it—§ i.
Sulph : potassa; et sodae § i.
Bitart: potassa; 3 ss.—3 i.
Aquae lb ii t>1 .
A tea-spoonful, or a table-spoonful, or a wine-glassful, may be given every two
hours, according as we wish the effect to be slight or otherwise. The circulation is
calmed, the skin determined t >, exhalation from the bowels maintained and the flow
of urine increased; in short, the result proves sedative, evacuant, and thoroughly
antiphlogistic.
ON CONGESTION.
133
fomentation, rest, and attention to position, are perfectly equal to the
remedial task ; subduing disease satisfactorily, and yet not enfeebling,
even temporarily, the general poAvers. When an important internal
organ, however, is being inflamed—as the lungs, kidney, bladder—we
are anxious to overcome the evil as soon as possible—as it were at
once to cut it down—saving both texture and function; in such cir-
cumstances we begin with full general blood-letting, repeating it once
and again until the symptoms are satisfactorily subdued. When not
only function of the part is important, but its texture also most deli-
cate—the efficiency of function dependent on the integrity of that tex-
ture—as in the eye and brain, Ave practice bleeding with equal alacrity
as in the former instance, and folloAv it up by the free use of mercury;
in some cases, full and continued doses of antimony may be substituted
for the mercury ; and in some, both of these medicines may be em-
ployed, as in pneumonia, each at its appropriate period of the case.
When excruciating pain attends inflammation of a part, especially if
this be an internal organ, after general and local blood-letting pushed
as far as the probably already depressed state of general vital poAver
will permit, our principal reliance must be placed in opium ; for, at all
hazards, such pain must be subdued if possible ; as in serious inflam-
mation of the boAvels. In rheumatic inflammations, opium, mercury,
antimony, are, as accessaries to blood-letting, often secondary to col-
chicum. For the chronic embers of an acute inflammation, counter-
irritation is most suitable; and this, preceded by moderate local
depletion, and accompanied by complete rest of the part, is most espe-
cially effectual in the cure of perverted action Avhich has been chronic
from the first. As all vital action, Avhether normal or perverted, is
usually slower in the hard than in the soft textures, to the chronic affec-
tions of the former counter-irritation is particularly appropriate. Again,
in certain very acute affections of soft parts, we trust chiefly to the
lancet and bistoury; as in erysipelas, and its phlegmonous and most
intense form.
The peculiarities of treatment adapted to the chronic as contrasted
with the acute form of the inflammatory process, are analogous to the
differences in the nature of the tAvo affections. As the action and its
symptoms are much less urgent, so are the means of treatment less
energetic and less truly antiphlogistic—less severely sedative and de-
pleting ; and as already stated, Avhen action has been arrested by such
mild measures, its final overthroiv, followed by gradual restoration of
the part to its normal condition, is to be mainly effected by j udiciously
conducted counter-irritation.
CONGESTION.
Congestion is of tAvo forms, the Active and Passive.
Active Congestion.—This has been already considered, as a part of
the general inflammatory process. It may be a mere preliminary to
12
134
PRINCIPLES OF SURGERY.
the true inflammation : or it may persist as the minor grade, constituting
a disease of itself.
Its causes are identical with those of the general inflammatory pro-
cess ; and the symptoms are such as have been already ascribed to that
process, slightly developed. Redness is considerable ; heat, SAvelling,
and pain are well marked, yet not intense. Effusion is not so rapid
as in true inflammation, and consequently there is little or no tension.
By continuance of even gentle transudation, hoAvever, structure may be
altered, and function interfered with. More or less febrile disturbance
may attend; but not of the true inflammatory type.
The results also resemble those of the general inflammatory process.
Resolution perhaps most frequently occurs, in the Avay formerly de-
scribed. Or advance is made to true inflammation, Avhen the minor
action becomes merged in the greater. Or the congestion simply per-
sists, and by continuance leads to change of structure. Effusion is
partly serous, partly fibrinous. The action, unlike true inflammation,
is not incompatible Avith organization of what is effused ; its fibrin is
therefore more or less plastic, and threatens by organization to become
permanent in its extravascular position. This may induce serious re-
sults, sadly impairing function, as in the parenchyma of an important
internal organ. Or the issue may be most salutary, as in the healing
of wounds and ulcers, more especially by granulation.
If congestion occur suddenly, and texture be delicate as well as vas-
cular, hemorrhage is not unlikely. If on a free surface, as mucous
membrane, no harm, but benefit ensues ; it is a spontaneous depletion,
probably critical, and ought not to be rashly thwarted ; to check such
a floAv prematurely may be virtually to convert, according to circum-
stances, haemoptysis into pneumonia, haematemesis into gastritis or
enteritis, menorrhagia into metritis ; that is, preventing resolution, and
compelling advance of the perverted action. If in parenchyma the
vessels give Avay, nothing but evil can follow on such extravasation ; it
is by all means to be avoided.
The treatment is gently antiphlogistic. Blood-letting from the part;
general, Avhen the texture affected is internal and important, and espe-
cially if tendency to hemorrhage and extravasation be dreaded—as in
the lungs ; antimonials ; saline purgatives ; rest; fomentation ; position;
and the antiphlogistic regimen. Should the action threaten to become
chronic, gentle counter-irritation is to be employed. For the results of
action, pressure, friction, and other means of gently stimulating absorp-
tion, are appropriate, should the natural effort of the part, Avhen relieved
from action, not be sufficient. But usually, unless the congestion have
been very long sustained, all the serous or fluid part of the effusion is
readily taken up by the voluntary act of the absorbents, so soon as the
vascular action, which previously held absorption in abeyance, has
ceased. During persistence of the congestion, much serous effusion
may have taken place into a serous cavity; by suitable antiphlogistics
the action has been subdued ; and very shortly afterwards the whole
of that acute dropsy will probably have disappeared, without any far-
ther remedy having been employed. Thus, for instance, simply hydro-
cele is got rid of. The original chronic serous collection is removed
ON CONGESTION.
135
by tapping; stimulation is applied to the serous surface by injection ;
acute effusion of serum folloAvs, and distends the activity again; but on
subsidence of the artificially induced action, this serum quickly disap-
pears ; and it is seldom that any reaccumulation even threatens, a
healthful balance having been established thenceforth between absorp-
tion and exhalation.
Passive Congestion.—This may follow on an imperfect resolution of
the active form, as does chronic inflammation on the acute. Or it may
be original, unpreceded by excitement. In the active form, the arteries
and capillaries of the part are chiefly implicated—dilated, yet carrying
on a tolerably vigorous circulation; in the passive, the capillaries and
veins are mainly concerned—dilated, but Avith a circulation much re-
tarded and depressed. The redness is of a dark hue ; little or no heat
is complained of; a sense of weight and dulness is felt rather than
pain; effusion is gradual, and chiefly serous—consequently, Avith en-
largement of texture Ave have neither tension nor induration ; function
is more or less disturbed. The characteristic symptoms, as contrasted
with those of the acute form, are the dark colour, comparative absence
of pain and heat, and soft doughy swelling gradually formed.
The causes of passive congestion may be shortly stated to be, 1. pre-
vious perverted vascular action ; 2. local debility from any cause, more
especially as evinced by atony of the blood-vessels; 3. obstruction to
venous return ; 4. alteration in the quality, and 5. in the distribution of
the blood ; 6. general debility. (1.) It has been already observed that
the passive form may be the consequence of the active ; the arteries
having recovered their normal calibre and play, while the capillaries
and veins remain distended and weak. Or the same may occur in
regard to a higher grade of previous action, the truly inflammatory;
from Avhose vascular distention and debility, Avith sluggishness of cir-
culation, recovery is less likely to prove rapid or complete. (2.) Local
debility, hoAvever induced—by inflammation, exposure to continued
cold, application of poison, mechanical injury—is manifestly favourable
to dilatation of extreme vessels, and weakness of circulation there.
(3.) Obstruction to venous return is still more plainly and directly a
cause of venous accumulation. It may be produced through position:
long maintenance of the erect posture tends to induce passive conges-
tion of the loAver extremities. Or there may be obstruction by com-
pression ; by ligature, tumour, or over-distention of a normal part.
Habitual use of a tight garter will occasion passive congestion of the
leg ; and a similar result will folloAV on the formation of a tumour in the
popliteal space or at the groin, as Avell as on distention, great and
habitual, of the lower boAvel by faeculent matter. (4.) Diminution of
the normal proportion of fibrin in the blood, retards its Aoav in the
extreme circulation, and so favours asthenic congestion—as in simple
fever, and in scrofula. (5.) Determination of blood to a part certainly
produces congestion there ; and if the part have been previously Aveak,
the congestion will probably be of the passive form. Thus an internal
organ, having just recovered from either active congestion or true inflam-
mation, Avith its vital power depressed, and the minute vessels still
large and of weak circulation, can scarcely escape passive congestion,
136
PRINCIPLES OF SURGERY.
if the patient imprudently expose himself to cold so as to cause decided
intropulsion of blood to it from the surface. (6.) General debility,
bringing at once proneness to unwonted determinations, with an easy
overcoming of the extreme vessels thereby, plainly favours passive
congestion. (7.) It not unfrequently happens that tAvo or more of such
causes occur in unison, rendering the establishment of the morbid con-
dition all the more certain. Thus the patient described under the fifth
head, may be of either scrofulous or scorbutic constitution ; and in his
case, all the causes will probably have concurred, excepting perhaps
direct obstruction of the venous return. And yet that need not be
wanting; he may have diseased heart, impeding pulmonic circulation;
or organic disease of the liver may seriously retard its venous Aoav—
either circumstance frequently occurring as the more immediate cause
of passive congestion, with its troublesome consequences, in the serous
cavities.
Results.—1. Resolution may take place, and is to be hoped for; but
at best it is a tardy process, and often incomplete. 2. Hemorrhage is
not so likely to occur as in the active form; and Avhen it does, it is of
an opposite character—still passive ; venous, dark coloured, in a quiet
slow stream ; but this stream, simply by being gentle and furtive yet
constant, may lead to serious loss of blood. Its continuance can
scarcely be expected to benefit the part, it cannot fail to hurt the sys-
tem, already Aveak and perhaps exsanguine; it may usually be arrested
therefore with but little ceremony or precaution—a practice very dif-
ferent from Avhat is applicable to a similar event in the active form.
3. Serous effusion is the characteristic result of passive congestion;
occurring slowly and gradually, yet accumulating in large quantity by
continuance; more aqueous, by containing much less albumen, than
the similar effusion of the active form; and most remarkably less
amendable to absorption, partly because of the remaining imperfection
of venous circulation, partly apparently from the lymphatics also being
depressed in function. It may take place into a serous or synovial
cavity, constituting a dropsy ; or into the parenchyma of a part,-forming
cedematous SAvelling. 4. Active congestion often leads on to inflam-
mation ; the passive more frequently folloAvs than precedes. And when
it does precede, it is only as a predisposing cause, demonstrative of
local debility ; not only favouring accession of more active disease, but
also diminishing the poAver of resistance and control.
Treatment.—1. Manifestly the first indication of treatment is to
remove the cause—Avhether that be ligature, faeculent accumulation,
unfavourable position, or structural change of some internal organ.
The last mentioned is, for obvious reasons, often accomplished with
difficulty, if at all; fortunately for us, however, it is a cause of passive
congestion of much more frequent occurrence in the practice of the
physician than in that of the surgeon.
2. An obvious cause having been removed, it is well to disburden
somewhat the over-distended vessels, as the second step towards their
reduction to a normal state. Punctures are applicable to the ordinary
surface Avhen thus affected ; scarifications to mucous membrane. The
serous effusion is at the same time permitted to escape, and the paren-
ON CONGESTION.
137
chyma thus also relieved. In affection of deeply seated parts, however,
we have to rest satisfied with less direct, and probably less efficient
means of obtaining this object—a derivant, instead of a directly evacu-
ant effect The blood is to be coaxed from the part—not so readily as
in the active form of congestion—by dry-cupping, sinapisms, or others of
the simple counter-irritant class; or blood may be actually drawn, in
small quantity, by leeches or cupping, from "the part's vicinity ; by
either procedure—the latter more likely perhaps—derivation is to be
expected, so as to relieve, to a certain extent, the gorged and indolent
vessels of the congested part.
3. The third indication—after having obtained as much relief, direct
and indirect, of the part as Ave can—is to stimulate the blood-vessels to
resumption of their wonted calibre and tone, and the absorbent system
to efficient discharge of exalted function ; so as both to prevent further
serous effusion, and-remove that Avhich has already taken place. Fric-
tion, at first gentle, and gradually increasing in vigour; pressure, uni-
formly applied, and also at first used gently—are obvious means of
obtaining fulfilment of this indication. They may be happily combined ;
the one mechanically favouring the retarded venous return, and indeed
accelerating the general circulation of the part, the other mechanically
promoting the restoration of normal calibre to the blood-vessels; both
vitally arousing the dormant energies of the part, as regards both nutrition
and absorption—more especially the latter function. Contraction of
the vessels may be further favoured by suitable local applications, as
zinc, alum, kino, galls, catechu, &c.—especially useful when a mucous
surface is the seat of the malady ; also by the internal use of general
tonics, as the preparations of bark and iron, the iodide of potassium, &c.
The latter class of remedies will, of course, constitute a prominent
remedy in those cases where marked general debility may seem to have
induced the local disorder, and, at all eArents, tends to its maintenance.
Stimuli are sometimes of use, not in procuring simple retrocession of
the morbid action, but by pushing it omvards to a higher grade, whence
recession is much more probable. Activity is grafted upon sloth;
Passive Congestion is converted into Active. Then, abstracting the
stimulus Avhich caused the change, and employing some of the gentle
means suitable to the new production, resolution may be hoped for
under circumstances much more auspicious. An example of this has
been already quoted, as given in the modern cure of simple hydrocele.
Other illustrations occur daily, in the stimulating system of treatment so
successful in removing passive congestions of the conjunctiva. Care
must be taken, hoAvever, that our OAvn creation become not worse than
the original malady ; in other words, seeking Active Congestion only,
we must avoid True Inflammation—for this occurring in a part of
weakened power, by previously existing disease, is tolerably certain to
advance to a result more or less disastrous to texture.
12*
138
PRINCIPLES OF SURGERY.
CHAPTER II.
PERVERTED ACTION OF THE NERVOUS SYSTEM.
IRRITATION.
This word is here used to denote a morbid condition, different from
Inflammation. In the latter we found the blood-vessels of the part to
be chiefly concerned in the morbid change, all the component tissues,
however, being, sooner or later, more or less involved ; here, the nerves
occupy a somewhat similar pre-eminence ; on perversion of their func-
tion, the diseased state mainly depends. The nervous function is
excited and perverted, by an irritative agent, applied either directly or
indirectly ; pain, and other anormal sensations, with more or less dis-
turbance of general function, result. The'blood-vessels are secondarily
involved, but not in a sthenic form: and such implication does not
effect such an alteration of the local circulation, as to lead to effusion
and change of structure thereby. The morbid state may be either local
or general.
Local Irritation.—Its signs are negative as well as positive. Little
or no increase of blood is to be found in the part, little or no effusion,
and no change of structure ; little unusual heat, and no swelling—unless
indeed there be a shade of tumescence by reason of an unwonted fulness
of the fibro-cellular tissue ; no redness—but sometimes a paleness of
the part, from temporary anaemia there—sometimes a livid hue, from
temporary passive congestion. Pain is the prominent symptom—some-
times slight, usually intense, occasionally excruciating'; unlike that of
inflammation, as great at the beginning as at the last; and not only
remittent, but intermittent; worse at one time that at another, and
during certain periods altogether absent. The general function of the
part is disordered ; secretion, for instance, may be either increased or
diminished in quantity, and variously altered in quality.
As examples of Irritation maybe mentioned, disordered function and
sensation of the rectum, by the presence of ascarides there—the pain
not often great, and usually merged in the sensation of itching; stone
in the bladder ultimately leads to various grades of perverted vascular
action in the coats, but at first may cause only Irritation—the pain in
this case is often severe ; simple decay of a tooth often produces aching
of an intense description, apparently altogether independent of vascular
action. Tic douloureux may be connected, more or less directly, with
structural change in the nerve; but in many cases, no such alteration
can be detected, and the case is one of pure Irritation—pain is invari-
ably severe, and often agonizing.
The cause of Irritation, is the application of an irritating agent directly
to the nerves of the part; or to the same nerves, at a distance from the
ON IRRITATION.
139
part affected: or to other nerves, intimately connected by sympathy
with those involved in the prominent functional disorder. The irritating
agent may be either external to the body, or of its own production;
foreign matter of any kind, for. example, applied from Avithout; or
structural change, the result of the inflammatory process, acting either
on the part itself, or on a distant portion of continuous tissue. Thus, a
rubbing of the surface produces irritation of the part rubbed ; stone in
the bladder produces irritation, both directly and indirectly—the latter
through reflex action,—in the coats Avith which it is in contact, and
also referred to the mucous membrane of the orifice of the urethra;
foreign matter lodged in the kidney acts in the same way ; and ascarides
of the rectum produced anormal sensation both there and at the other
extremity of the mucous canal. Disease of the hip-joint causes irrita-
tion at the knee ; affection of the liver, at the shoulder ; disease of the
uterus, in the mamma; structural change in the brain is suspected, not
without good reason, of inducing some of the most intractable forms of
neuralgia in the face. Again, an irritating "agent applied to one part of
the body may induce an irritation in another, with which it has no
apparent connexion, either by sympathy of function, or by continuity of
nervous or other tissue. Foul matter lodged in the primae viae, for
example, may occasion irritation in the face or in the heel; ceasing on
effectual discharge of the noxious faeculent matter.
Although many examples of irritation are afforded by neuralgia, it
is not to be supposed that the terms are strictly syonymous. Neuralgia
is of tivo kinds ; a perverted nervous function only, or this dependent
on organic change in the nervous structure. It is only the former which
constitutes true irritation; structural change may be the cause, the irri-
tative agent, but is not the disease itself.
Inflammation and irritation are in themselves. plainly distinct; yet
the latter may induce the former—vascular excitement, of a true
sthenic type, following on the nervous disorder. In fact, under such
circumstances, this irritation may just be considered analogous to the
nervous disorder, much more brief in duration, which precedes the
ordinary establishment of the inflammatory process. The period of
incubation may be said to be peculiarly long. The change having
occurred, hoAvever, the minor action—irritation—becomes merged in
the greater, inflammation ; the two are incompatible. Thus stone in the
bladder may give first irritation there, and then cystitis; simple tooth-
ach may be followed by gumboil; irritation at the orifice of the urethra,
from lodgement of foreign matter in the kidney, may be followed
by puriform discharge, stimulating ordinary gonorrhoea; ascarides, after
much direct irritation, may lead to abscess from inflammation of the
boivel.
Treatment.—The indications of treatment are obvious and simple ;
1. to remove the cause ; and 2. to allay the perverted function of the
nerves. Often it is sufficient to fulfil the first. Take away stone from
the bladder, ascarides from the rectum, a carious tooth from its socket,
and in many cases the irritation will be found to have disappeared
very speedily thereafter. If not, then have recourse to the direct ap-
plication of sedatives and anodynes to the part; and sometimes this
140
PRINCIPLES OF SURGERY.
class of remedies may also be exhibited internally with advantage.
Heat it is well known, is powerful to subdue nervous pain. It is to
the steam of hot water that Dr. M'Artney trusts for allaying nervous
disorder preceding vascular action, after Avounds or other.mechanical
injuries. And heat, either dry or moist, is by the voice of every-day
experience declared highly available in mitigating the.symptoms of
irritation of the boAvels, as Avell as of the simply neuralgic form of tooth-
ach. Opium, indisputably anodyne, may be used in various ways; it
may be gently rubbed on in a liquid form ; it may be laid on as a poul-
tice or plaster ; or the skin may be exposed by a simple vesicant, and
a salt of morphia sprinkled on the ravr absorbing surface. Lately it
has been proposed to make direct use of the salts of morphia, by inocu-
lation ; and the practice has been followed with some success. Hydro-
cyanic acid may be applied in the form of lotion, or cautiously painted
on the part Avith a hair pencil. Or belladonna, conium, or other selec-
tions from the anodynes, may be similarly employed. ^
Stimuli may be used indirectly, someAvhat on the principle of counter-
irritation ; and sometimes they give relief; a blister on the surface may
mitigate a deep-rooted irritation. But they should not be applied
directly to the part, othenvise they will very probably rouse the vas-
cular action in a sthenic form, inducing inflammation.
General or Constitutional Irritation.—In this case, perversion of
function is not limited to the nerves of the part—more particularly
marked in the sensory—but pervades the whole system, and does not
appear to be especially connected with the function of sensation. As
in local inflammation we found the vascular excitement in the part to
be first sthenic, and then more and more to pass into debility and
lentor ; so in general irritation, it is probable that the first disorder of
the nerves is sthenic excitement, sooner or later declining into an
asthenic perversion of function. The entire frame suffers in conse-
quence, and the febrile disturbance is of a Ioav type, wholly different
from the inflammatory. The average nature of the symptoms may be
stated as follows : Strength is more or less impaired ; anxiety is ex-
pressed by the countenance, and alarm by the words, tone, and gesture
of the patient; he is restless—local irritation induces change of posture
oft repeated, much more will an irritation which is general; sleep is
snatched, disturbed, and unrefreshing ; there is great susceptibility of
external impressions—especially at first, the sthenic form of excite-
ment being not yet past—the slightest touch, movement, or sound,
suffices to startle and alarm ; in general the surface is pale, cold, and
contracted—occasionally a dry heat and flushing pass transiently over
it; the countenance is pale and shrunk—sometimes, like the general
surface, temporarily flushed—sometimes stained by a circumscribed
spot of red ; the pulse is rapid, but neither full nor hard—sometimes
giving the sharp nervous jerk, and leaving the vessel, between the
beats, as if collapsed and empty—often small, indistinct, and flutter-
ing—occasionally intermittent—indicating impotent alarm of the gene-
ral circulation, instead of energy and tone as in excitement of the
inflammatory type; the tongue is at first loaded, whitish, and moist—
ultimately becoming dry, glazed, and preternaturallj clean ; the stomach
ON IRRITATION.
141
is often, but by no means invariably, disinclined for food, and is apt to
reject the little which it'receives ; general secretion is at first very much
impaired, giving arid skin, confined boAvels, and scanty urine—after-
wards it is much increased, giving profuse SAveating, diarrhoea, and
copious diuresis—evacuations by no means critical, or resolutory of
the disorder, but exhausting by impotent profusion. Frequently, after
the morbid condition has existed for some time, Nature seems to rouse
herself to an effort toAvards recovery by reaction, indicated by rigor.
This may be folloAved by heat and sweating of a better kind, tending
truly to resolve the disorder ; from that time the symptoms begin to
abate, and amendment advances satisfactorily, until the just balance of
health is absolutely restored. But the salutary effort may fail; and
then the downward course becomes more marked and rapid. The
functions of organic life become more and more deranged. Respira-
tion, before merely accelerated, becomes embarrassed and quicker in
its draught; the pulse is more feble, rapid and indistinct; the cerebral
functions become and more impaired, as evidenced by delirium,
often followed by coma ; strengh is speedily prostrated ; secretion is
again arrested, excepting perhaps diarrhoea, Avhich now is truly colli-
quative ; sinking in truth is established, and soon closes in death.
Causes.—The constitutional form may folloAV on the local; as in-
flammatory fever seems in most cases to be the consequence of local
inflammation. An irritation of the boAvels, if considerable, and at all
continued, will not fail to induce general disorder, marked by symp-
toms such as have just been enumerated. Or constitutional irritation
may be the remote result of local inflammation. The immediate effect
on the system is inflammatory fever ; but serious change of structure,
with suppuration, having taken place in the inflamed part, sthenic
constitutional disorder passes away, and is merged in one of an asthenic
type—Irritation. Hectic, as formerly stated, is one of the forms of
this disorder. And thus Ave see that although irritation and inflamma-
tion are morbid states distinct and incompatible, yet the one may pass
into the other ; in the general as Avell as in the local form. Local
irritation may be the means of inducing local inflammation; general
irritation may supervene upon inflammatory fever. And in practice it
is highly important to bear in mind the possibility of such trans-
mutation.
Error in practice may effect a more serious change. If, in a case of
constitutional irritation, the stimulant system of treatment be adopted
prematurely yet actively, the vascular system is probably roused into a
sthenic effort; inflammatory fever may ensue, but Usually the effort is
only partially successful. It seems as if an endeavour were made
toAvards a supremacy of vascular action over nervous; in other words,
to induce inflammatory fever. The effort, hoAvever, usually falls short
of the aim, and Irritative instead of Inflammatory fever is the result; a
condition of the system formerly stated to be of an intermediate char-
acter between constitutional inflammation and irritation, and one almost
invariably attended Avith much hazard to the frame.
Treatment.—1. As in the local form, the first and paramount indica-
tion is removal of the cause. Its efficient fulfilment is often alone equal
142
PRINCIPLES OF SURGERY.
to the cure. Take aAvay the intestinal irritation, and the constitutional
disorder quickly folloAvs ; remove the hectic cause, and usually the fever
speedily subsides1.
2. Calm the nenrous system. Of the calmatives, it is plain that
those are to be preferred—at least in the first instance—which are not
likely to over-stimulate the vascular system ; for some, as opium, un-
doubtedly have this effect, while sedative to the nervous ; and our
object is simply to subdue the ill we have, Avithout endangering the
occurrence of another still more serious. Irritative fever under any
circumstances is a formidable evil, but, seizing on a system already
low and Avorn, is likely to lead to the most disastrous consequences.
Hyoscyamus is justly a favourite remedy. It is not powerful either as
an anodyne or as a hypnotic, but " not poppy nor mandragora" soothe
so unexceptionably ; given in the form either of tincture or of extract;
in the latter, sometimes usefully combined with camphor—when inflam-
matory tendency is not dreaded. One other advantage henbane pos-
sesses, in not interfering with the secretions, but rather favouring
exhalation from both skin and boAvels. Hydrocyanic acid is a power-
ful and often most satisfactory calmative, more especially in those
examples of constitutional irritation folloAving a local irritation of intes-
tinal or gastric mucous membrane. Conium is often useful, and may
be given freely, unless palling on the stomach. Aconite and bella-
donna are also advantageous, in small doses, carefully conducted. In
the advanced stage of the disorder, opium is highly beneficial, espe-
cially in the form of morphia; now we scarcely dread an over-excite-
ment of the vascular system ; on the contrary, an increase of its tone is
desirable ; and Ave .are glad to avail ourselves of the poAverful narcotic
influence. The'tendency to an arrest of secretion may be obviated by
combination.
Sometimes the second indication may be happily conjoined with the
first. Thus—again recurring to the example of intestinal irritation—Ave
often remove the irritating agent, while at the same time a calmative is
applied both to the part and the system ; by the administration of castor
oil with laudanum, calomel Avith opium, blue pill Avith henbane.
3. Restore secretion. The ordinary diaphoretics, diuretics, and laxa-
tives are available for this purpose. But the indication must be ful-
filled gently and Avith caution. Profusion, with suddenness, might
increase debility, tending to aggravation of the disorder.
4. Support the system. As the disease advances, the system gives
way ; while it is our object to arrest the former, it is not less our duty
to enable the latter to bear up under its burden. Disinclination for
food is by no means so marked as inflammatory fever ; not unfre-
quently the appetite is tolerably good ; sometimes it is little if at all
impaired. It is to be indulged with nutritious and simple food—yet
in moderation; given often, and in small quantities ; for digestion is
weak, and the additional source of farther irritation by lodge mint of
undigested matter in the primae viae is certainly to be avoided. By
and bye, food may fail in its sustaining effect on the system, the sto-
mach grows weary, and digestion is Aveaker than before. More direct
tonics are to be had recourse to ; and the sedatives are laid aside ; for
ON THE SHOCK OF INJURY.
143
now the nervous and vascular systems are both in a state of depression.
Quinine, calumba, chirayta, &c. are given—yet cautiously; for all risk
of the induction of irritative fever has not altogether gone by. Effects
are watched, and the tonics increased or diminished accordingly.
5. The disease continuing, both food and tonics become ineffectual.
Stimuli are to be administered. Friction and heat to the surface ; wine,
brandy, ammonia, internally—in small doses, oft repeated. In the use
of the alcoholic stimuli, cautious management is most especially neces-
sary. The first effect of a full dose is stimulant, the second just as
poAverfully sedative ; marked depression IoIIoavs on the marked excite-
ment. It is our wish to produce and maintain the first, and by all
means to avoid the second. Minute, or at least moderate doses are
therefore given, sufficient to produce excitement—measured not by the
wine-glass but by the tea-spoon ; the effect of each dose is watched by
a competent and assiduous attendant; and so soon as the stimulant
effect begins to be departed from, and not before, the dose is repeated.
In the same Avay, as in the local antiphlogistic prophylaxis, Ave saw it
to be expedient to have the first effect of cold continuously maintained,
while the second Avas carefully avoided. And not only is caution
requisite to guard against the depressing effect of too large doses, at too
long intervals; there is yet danger of over-stimulation ; the opposite
extreme may be reached ; reaction may be induced, in a turbulent,
excessive, and unmanageable form ; inflammatory fever is not likely,
but irritative fever is far from impossible. In the last stage, opium is
usually unadvisable. When much sleeplessness, jactitation, or undue
efforts towards reaction exist, it may be given ; but warily, and even
with an umvilling hand; never in large doses, lest narcotism be ap-
proached, and sinking thereby accelerated.
Should over-action have been in any Avay induced, tonics and stimuli
are to be desisted from for the time, and sedatives—perhaps with an
antimonial—cautiously resumed.
It is very obvious how careful we should be, in not confounding this
form of constitutional disorder with that of the sthenic or inflammatory
type. Antiphlogistics, more especially if recklessly and freely em-
ployed, must tend to confirm the disease, and probably hasten its fatal
issue. And the same remark may be generally applied to local irrita-
tion also. " Blood-letting aggravates neuralgia, and relieves inflam-
matory pain ; steel and arsenic aggravate inflammatory pain, and cure
neuralgia."*
THE SHOCK OF INJURY.
More or less depression of the nervous system, with a secondary and
similar result on the sanguiferous, is usually the immediate result of
mechanical injury inflicted on the living frame : proportioned in extent
* TraverB.
144
PRINCIPLES OF SURGERY.
to the intensity of the external violence, the amount of the portion in-
jured, the relative importance of the injured part in the general animal
economy, and the previous state of the system ; of an aggravated cha-
racter, for example, Avhen a part of a limb has been crushed to a jelly
by a heavy weight; when a whole limb ha3 been bruised, scalded, or
burned ; Avhen an internal organ, such as the li\rer, kidney, bowels,
lungs, or brain, has in any considerable degree sustained mechanical
injury: when an injury, perhaps in itself not very severe, has been done
to a frame either originally weak, or enfeebled by intemperance, pre-
vious disease, or either extremity of age. In military practice, bullet
wounds of the trunk are often judged of according to the amount of at-
tendant shock ; if depression be slight and transient, the probability ia
that the Avound is but superficial., and at all events that the important
internal organs have escaped: if it be both great and protracted, the
prognosis is on the contrary unfavourable, the inference being that the
wound has reached a vital part.
The symptoms of nervous shock, after injury, vary from the slightest
appreciable loAvering of the vital poAvers, to complete syncope. Ordi-
narily, the patient falls, and lies helpless, cold, shivering, more or less
unconscious, and, when rojised, probably incoherent; convulsions may
supervene; the pulse is rapid, small, fluttering, indistinct; respiration
is imperfect and sighing ; nausea and vomiting are common—the latter
not unfrequently preceding reaction, and seeming to be concerned in
its induction; a cold, dank sweat bedeAvs the shrunk and pale surface;
the features are collapsed; the countenance bears a someAvhat anxious
expression, or else, by entire muscular relaxation, is a vacant, death-
like blank; the eyes roll wildly and restlessly, or else are fixed in an
upward, listless stare, with the upper eyelid partially closed over the
pupil; often the sphincters are relaxed, faeces and urine seeming to
pass involuntarily ; sometimes the secretion from the kidneys is sup-
pressed ; the cerebral functions become wholly suspended, the heart's
action ceases, and existence terminates.
Sometimes such symptoms abate rapidly, reaction quickly com-
mencing, and soon becoming completely established ; sometimes, they
persist for hours, reaction proving both late and gradual; not unfre-
quently reaction fails, sinking is again progressive, syncope is com-
plete, and life becomes extinct.
Reaction—or a more or less gradual return towards health—is usually
preceded by a distinct rigor, and very often by full vomiting. The
nervous system is restored, and the sanguiferous is proportionally re-
lieved from depression. Sensation, poAver of motion, intellectual func-
tion, special sense, gradually return. The patient becomes conscious
of his state, and inclines to inquire into it; his manner grows less wild
and agitated, his eye is steady and intelligent, his countenance less
anxious, his features more full and composed ; secretion again becomes
normal; the heart beats with gradually increasing power and regularity;
the pulse becomes more full and equable, and is felt distinctly in the
extremities ; heat comes back to the surface, and this parts with its pale
anserine appearance. The patient recovers himself, in short sits up,
ON THE SHOCK OF INJURY.
145
fcnd once more becomes an intelligent member of the world around
him. This may be the result of Nature's effort, alone and unaided; or
our art may assist in its induction.
Whether its commencement be spontaneous or not, its progress
should always be watched most carefully. The action may advance
favourably to completion, and proceed no further than the attainment
to the even balance of health ; little or no extrinsic aid being required,
either then or subsequently. Or it may overstep the bounds of health,
and pass into disease ; producing either irritative or inflammatory fever,
according as the excess is of a sthenic or asthenic character. Or the
salutary effort may be imperfect from the first, and asthenic throughout;
partial restoration of pulse, consciousness, and general warmth being
quickly folloAved by relapse ; a febrile accession occurs, but is of the
typhoid character, tending to renewed prostration, collapse, and death.
Again, in the case of lesion of certain internal organs, as the brain,
the premature occurrence of simple reaction may prove calamitous, by
escape of blood from the injured part, unfavourable to persistence or
resumption of function. And even from an ordinary wound, the pro-
gress of reaction must be regarded, otherwise an inconvenient hemor-
rhage may ensue.
But the shock of an injury may be considered practically as of two
kinds—mental and corporeal. In the case of the former, the patient—
to use an ordinary phrase—is more frightened than hurt. The wound
in reality is but slight, yet the attendant shock is great; it is, however,
transient. Its origin was mental; alarm, being great and sudden, ex-
ercised a most poAverfully depressing influence on the brain and general
nervous system, Avhich again lowered the circulation, and the combined
result may have been a near approach to syncope. But so soon as the
mind has been reassured—the injury being both seen and felt to be in
truth trivial—the depression passes aAvay, and by reaction the balance
of health is soon re-established. The practical importance of distin-
guishing between this and the more real shock, may be thus illustrated.
Suppose a patient about to undergo an operation on account of mecha-
nical injury done to a comparatively unimportant part, and plainly
labouring under depression of the general vital poAvers—shivering, pale,
cold, breathing rapidly, of an alarmed expression, and almost pulseless.
If this state is but of mental origin, the preparations for operation may
be continued ; a feAV words of kindness and comfjprt, with perhaps a
mouthful of Avine and water, will probably suffice to establish almost
instant reaction. Whereas, if the cause be altogether unconnected
with mental impression, the patient may be removed from the operating
table to bed; for, some considerable time must necessarily elapse, ere
the system can have recovered itself so far as to possess a tolerance of
operation. The one form of shock is in its nature very transient, the
other more or less enduring.
There are many cases in which both forms of shock are more or less
combined, as can be readily imagined. For example, a man may be
mortally Avounded by an unexpected and unseen foe; the shock of the in-
jury Avill be great, although entirely corporeal in its origin. A second
may receive only a scratch, while he expected nothing but instant death ;
146
PRINCIPLES OF SURGERY.
the shock will be serious, and may indeed amount to actual syncope; yet
it is purely mental. A third may sustain a serious injury, from an as-
sailant both seen and feared ; the shock will probably be intense ; mental
and corporeal impression both contributing towards the lpAvering result.
In such cases as the last, it is practically useful to ascertain if possible—
by inquiry into the history of the accident, and as to the natural tem-
perament of the patient, as well as by carefully noting the existing
symptoms—in what proportions the combination has probably oc-
curred.
Treatment.—In the mental form, as already stated, reassurance and
a little time are sufficient to recover the patient. In the corporeal, two
errors—in their nature very much opposed—require to be guarded
against; foolish bleeding, and premature stimulation. A patient haying
received a fall, is probably found unconscious and incapable of motion;
the practitioner would seem, in some instances, to have a peculiar apti-
tude for mistaking such a state for the coma induced by extravasation ;
a vision of apoplexy, with its suitable remedy of venesection, passes on
the instant through his mind ; his lancet, as it were mechanically, leaves
its case, and reaches a vein in the bend of the arm, or the jugular vein,
or the temporal artery. No blood may folloAV the incision; and it is
well; for loss of blood—a most powerful agent of depression—is not
likely to prove beneficial Avhen depression is already great and danger-
ous. By and bye, reaction begins to be established ; the pulse ntay be
felt and counted, the skin becomes warm, and signs of returning con-
sciousness appear ; at this stage, bleeding is not ^frequently practised;
still it is premature. Nature now, however, is in a better state of self-
defence ; but little of the precious fluid escapes, ere syncope again oc-
curs, arresting the flow—a protest and a safeguard against the mala-
praxis. The time for bleeding is neither before reaction nor during its
early progress, but after it has been fully established, and when it
threatens to advance to an inflammatory excess.
Again, let us suppose that the case is not one of simple concussion,
but That lesion of the cerebral structure has occurred. Perhaps the
shock—for at first the symptoms may be those of concussion only—is
of long continuance ; hours may elapse, and yet the circulation is weak,
and almost limited to the trunk. This is well; for during such a con-
dition, hemorrhage is not likely to take place from the injured texture;
time is afforded for the completion of Nature's temporary haemostatics;
when reaction does occur, and activity of circulation is restored to the
brain, bringing with it return of function, no open vessels permit san-
guineous extravasation; coma by compression has been happily pre-
vented. This is a beautiful adaptation of circumstances to the attain-
ment of an important and salutary event; let the surgeon look on in
passive admiration. But not unfrequently, he is tired of waiting on
Nature, and administers stimuli at an early period to bring about reac-
tion ; he unfortunately is successful in his short-sighted aim; circula-
tion is restored to the torn part while its vessels are yet open, concus-
sion is converted into compression, and danger to life is increased
ten-fold. Under such circumstances—and they are not unfrequent in
occurrence—early recourse to stimuli is strongly reprehensible; the
ON THE SHOCK OF INJURY.
147
ractice must prove in all such cases prejudicial, in not a few it will
e certainly fatal.
In the treatment of the shock of injury, then—and more especially
when the head is the part injured—early bleeding and immature stimu-
lation are both to be avoided. The injured part receives the mecha-
nical adjustment that is necessary, the patient is laid in bed, or else,
where, as comfortably as possible : Avith the head (unless it be the seat
of injury) in the first instance rather low, so as to favour return of ar-
terial circulation there. The event is then carefully watched. Reac-
tion may soon occur, Avithout further aid from us, and require even
active means for its moderation. When it is tardy, and there seems to
exist no reason why its retardation should be desirable, friction and
heat are to be applied to the general surface; and should these fail,
stimuli are then cautiously administered by the mouth ; beginning Avith
simple fluids, such as hot tea or soup, and gradually ascending in the
scale, if need be, to brandy and ammonia. The exhibition of these
requires care, Avhen insensibility is complete ; othenvise they may get
into the air passages instead of into the gullet, and suffocate the patient.
Also in urgent cases, powerful stimuli-1—as sinapisms, hot irons, blisters,
strong ammonia—may be applied to the surface, with the double ob-
ject of rousing the spinal system by reflex action, and courting sangui-
neous circulation towards the part irritated. In the use of such reme-
dies, it is to be remembered that sensation is for the time in abeyance;
and unless we—as it were—feel for the patient, the applications are
apt to be unnecessarily severe ; proving very troublesome, and perhaps
even dangerous, in their results, after reaction has been established—
as by ulceration, sloughing, or extension of superficial inflammation.
The ammonia, for example, of a smelling bottle has often been carelessly
throivn into the nostrils, producing sad disturbance there ; during the
syncope, the patient is unaware of the receipt of this fresh injury; but
very soon after reaction, the effects of the over-done remedy may largely
predominate over those of the original accident; lives have actually
been lost by nasal inflammation, so induced, having extended to the
cranial contents.
The internal use of stimuli must also be conducted with extreme
caution, and desisted from so soon as circulation is restored satisfac-
torily ; otherwise danger by excessive reaction can scarcely be escaped.
If inflammatory fever set in, along Avith local inflammation in the in-
jured parts, not only are all stimuli scrupulously Avithheld, but antiphlo-
gistics are administered as circumstances may demand. If, on the
other hand, irritative fever be the result, opium or other narcotics, in
guarded doses, are to be exhibited. And it is to be borne in mind
that Avhen the shock has been severe and protracted—and more espe-
cially Avhen it has occurred in a frame previously Aveak—the sthenic
period of reaction is apt to be but short, and the tendency is to gan-
grene locally, with typhoid seizure of the system ; in such cases the
more powerful antiphlogistics must be employed sparingly, if at all.
When the injury has been attended Avith great loss of blood, reaction
is never of the sthenic form, but of the purely nervous kind, formerly
148
PRINCIPLES OF SURGERY.
described when treating of venesection; for the assuaging of this, a
full opiate is most effectual
Vomiting usually disappears before the ordinary restoratives, along
with the other symptoms of the shock. Should it prove troublesome—
as it sometimes does, with hiccup—it may be directly treated by &
sinapism to the epigastric region, and small doses of the spiritus am-
moniae armaticus.
Thus we see the dangers of shock after injury are, 1. Continued depres-
sion, sinking, and death ; to be met by restoratives, and with abstinence
from blood-letting and other sedatives during the early period of the
nervous commotion. 2. Inflammature and excessive reaction of a
sthenic and. vascular character; to be met by blood-letting, and other
antiphlogistics; the use of restoratives being of course refrained from.
3. Excessive reaction, probably remote, of a nervous type ; to be met
by opiates and other calmatives, cautiously administered. 4. Asphyxia,
or other disaster, by the use of stimuli and other restoratives; to be
avoided by care, prudence, discretion, and coolness on the part of the
practitioner.
CHAPTER III.
PERVERTED ACTION OF THE ABSORBENTS.
That absorption is effected partly by veins, as well as by the lym-
phatic vessels, specially adapted for the function, seems now to be
generally admitted. This, occurring in excessive proportion as regards
the antagonist function of nutrition, produces various effects on the part
involved in such departure from health. And it is plain that the anormal
state may depend either on excess of absorption or on deficiency of
arterial supply.
When the capillaries of a part deposit an amount of plasma simply
sufficient to supply what is dissipated by the current waste, the result
is normal; the condition is that of health. When more is exuded than
is required to atone for waste, the existing play of the absorbents is
unable to prevent accumulation of the excess ; the condition is a morbid
one, and termed hypertrophy. When, on the contrary, the deposit
from the capillaries is insufficient, by deficiency of arterial supply; or
when the absorbents exercise their function to an unusual degree, the
condition of the blood-vessels remaining unaltered from the state of
health—the result is of an opposite kind—still morbid—and called
atrophy.
ON ABSORPTION.
149
Atrophy.
Atrophy of a part, we have just seen, may occur from excess of waste,
or from deficiency of supply. In most cases it is probable that both
circumstances concur to establish the result, although the major part is
attributable to the latter. The part is gradually diminished in bulk, its
structure usually becomes somewhat modified, and its function is more
or less deranged.
This state may follow on inflammatory action; as a remote conse-^
quence, not as a direct result the connexion is usually with the chronic
form. That action ceasing, the absorbents busy themselves to remove
the loaded change of structure; and it is not unlikely that this exalta-
tion of their function may be continued beyond what Avas necessary to
restore the healthful balance. Besides, disuse of the part, which
attends to chronic inflammation, will necessarily have the effect of
diminishing the arterial circulation ; and this latter cause of wasting
may be further contributed to, by a remaining change of structure in
the part itself. Or any of these causes may of themselves be equal
to the result. Thus, a testicle, which has been simply inflamed, may
become simply atrophied; a limb which has been long disused, on
account of inflammatory disease of a joint, or from any other cause,
invariably is more or less wasted ; granular disease of the kidney is"
accompanied or followed by decrease in the bulk of that organ.
Treatment. The indications are simple. To allay the actionof the
absorbents ; to strengthen that of the blood-vessels, more especially of
the arterial system. The former is attained by gentle counter-irritation
—as slight blistering, or inunction of croton oil. The latter, probably
the more important of the two, is fulfilled by use of the part, friction,
and electro-magnetism if necessary; with resumed function, the nutri-
tious effort is aroused, and normal development usually restored.
Atrophy may not be limited to a part, but affect the Avhole system ;
the result of imperfect nutrition—in many ways induced. But this
general morbid state comes not within the peculiar province of the
surgeon.
Interstitial Absorption.
This may be termed atrophy of a portion of a part, and is most fre-
quently found in the hard tissues ; a more direct result of a low form of
perverted vascular action, and dependent chiefly if not wholly, on an
exalted and perverted exercise of the absorbent function. The process
is most distinct in bone, converting Avhat was dense into cancellated
texture ; or, by being limited to certain points, interspaces of normal
tissue remain, imparting a worm-eaten appearance to the whole. The
super-imposed soft textures are usually in a state of passive congestion.
The part is slightly swoln, puffy, and darkly discoloured ; there is a
deeply-seated dull gnawing ache, rather than pain, aggravated by firm
pressure. Weakness is complained of in the part; and marked increase
of the uneasy sensations follows exercise of it, even when gentle. The
13*
150
PRINCIPLES OF SURGERY.
affection is most likely to occur in those of weak frame, and is usually
attributed to external injury. In general, dull uneasiness has been felt
in the bone, before any affection of the soft parts became recognised.
The treatment consists of gentle counter-irritation, rest of the affected
part, and attention to the general health.
This morbid state of bone is found to be of much importance, not so
much on its OAvn account, as in consequence of its being the precursor
and accompaniment of one of the most troublesome diseases with which
our art has to contend—caries.
Continuous Absorption.
This differs from the preceding in being continuous, instead of
interstitial or interrupted ; and, being usually both continuous and pro-
gressive, it occasions more or less loss of substance. It may follow,
more or less remotely, on perverted vascular action; or it may be
accompanied by some such action. But in many cases it seems to be
almost wholly unconnected with vascular change, and in all is altogether
separate from true inflammation. The loss oi substance is a gradual,
almost painless, and altogether pus-less process ; the Avork of the absor-
bents alone. And thus it manifestly differs most widely from true
ulceration.
It has its analogue in the opposite condition of repair, or restoration
of lost substance. A chasm of the soft parts may be filled up by granu-
lation, or by the " modelling process." The former is preceded by
true inflammation, and is analogous to ulceration. The latter is not
only unconnected, but incompatible with true inflammation, and is
analogous to continuous and progressive absorption ; the one is simple
removal, the other simple deposit; both are unattended Avith inflamma-
tion, and both are consequently unaccompanied Avith the formation of
pus. To both the absence of atmospheric contact is essential. Admit
this, and inflammation follows—the consequence of sudden and power-
ful stimulus acting on a part already in an unsound condition. The
simple absorption is converted into true ulceration ; the modelling pro-
cess is arrested, ulceration overturns what has been already done
towards repair, and then, this destructive action subsiding, restoration
commences again in a new way, by granulation.
Familiar examples of this form of absorption are afforded by the
gradual disappearance of texture, both hard and soft, before slowly
increasing pressure; as by abscess, or by aneurism. And pressure
may be considered as by far the most frequent exciting cause. This,
according to the amount of its dose, produces different effects. Sudden
and great, vitality may be at once destroyed in the part; a less amount,
gives ulceration ; less, simple inflammation ; less, a perverted vascular
action short of the truly inflammatory; still less, gradually applied,
with exclusion of atmospheric influence, affects the arterial and capil-
lary vessels little if at all, while it excites the absorbent vessels to the
morbid result now under consideration.
The treatment consists of abstraction of the cause—usually pressure-
rest of the part, and moderate counter-irritation. The two first, and
ON SUPPURATION.
151
more especially the first, are the most important, as can be readily
understood ; and when they have been satisfactorily fulfilled, but little
of the last will be required. When the morbid condition has been
arrested, the loss Avhich it has occasioned is quickly and simply repaired,
by the accession of its analogue the " modelling process;" simple
non-inflammatory deposit coming in the place of simple non-inflamma-
tory absorption.
CHAPTER IV.
SUPPURATION.
Pus, it has been already stated, is invariably the product of inflam-
mation ; and may be effused either into the parenchyma of a part, or
on its free surface. The former condition is termed abscess—of great
frequency of occurrence, and of much import to the practical surgeon.
Abscess.
Acute.—When suppuration follows on the inflammatory process, of
an acute and sthenic kind, Ave find the morbid state resolvable into
three parts, as formerly stated ; capable of being represented by con-
centric rings. Within the central will be found the pus, extravasated
blood, and broken up original tissue. Within the second, is fibrinous
effusion, at least partially plastic, and more or less advanced toAvards
organization ; limiting, or tending to limit, the suppuration within the
central space. The third or external circle represents the diffuse serous
infiltration which invariably surrounds, more or less, the central and
more important change.
When this state has continued for some time—and more especially
when the duration is such as to warrant the appellation of chronic being
applied to the abscess—the limiting fibrinous deposit becomes more
and more condensed, its central aspect ultimately assuming a mem-
branous appearance and a membranous function; having a smooth
villous surface, somewhat like the mucous, and possessing the power
of maintaining the formation of pus. Hence it is termed the Pyogenic
membrane ; endowed Avith very considerable powers of secretion, but
as an absorbent surface comparatively feeble. In regard to this latter
point, it may be useful to remember that the pus globule, when extra-
vascular and complete, is of comparatively large size, not soluble in its
own serum, and therefore but little amendable to ordinary absorption ;
the serous portion may be taken up readily enough, but the solid pro-
bably remains but little affected. And thus the feebleness of absorbent
power may depend not so much on deficiency of either structure of
152
PRINCIPLES OF SURGERY.
^ function in the pyfogenic membrane, as on the nature of the fluid on
which it has to operate.
Sudden suppression of the purulent formation is to be always regarded
as an untoward event. It is more liable to occur in the case of free
and open suppuration, than in an unopened abscess. It may be the
result of some accidental occurrence, the nature of Avhich it may be
difficult at the time to ascertain, or of injudicious stimulation wilfully
applied to the part, reinducing the true inflammatory crisis, and for a
time at least arresting secretion. It is liable to be followed by irritative
fever, usually of a formidable kind, and Avith difficulty allayed. Or, on
the other hand, the local result may follow on the general. A patient
labouring under a discharging wound, may become the subject of febrile
accession, altogether independent of the previous affection ; and during
persistence of such fever, the purulent as Avell as the other secretions
will be either arrested or impaired.
Supposing that no accident occurs, the usual course of the abscess is
to enlarge, and to approach the surface. The purulent is a waste
aplastic fluid, to all intents and purposes a foreign matter, and must be
removed. We have just seen that it is little liable to absorption ; the
only other alternative of removal is by direct evacuation.' In most
cases this should be the work of the surgeon. But Nature has a mode
of her own, and is to a certain extent independent of his interference.
The process is as follows : The matter, by continuance of the secretion,
gradually and steadily accumulates in larger quantity ; and the effect of
such accumulation plainly is to make pressure on the surrounding parts.
They are thus to a certain extent pushed aside to accommodate the
increasing fluid ; but the accommodation so obtained is insufficient,
and the pressure, not being relieved by adequate extension of texture,
occasions more or less absorption of the parts compressed. The fibrin-
ous barrier is not undone, but pushed back; and the surrounding parts
are partly condensed by the mechanical result, partly diminished by
interstitial absorption, the vital result of the pressure applied. As
expansion of the barrier and cyst takes place, these are not attenuated,
but, by continuance of fibrinous deposit, are maintained unbroken and
efficient; the interstitial absorption is in the textures exterior to them,
comparatively uninvolved in the original action. According to mere
physical laAvs, this pressure, effecting an enlargement of the suppurated
space, should act equally in all directions ; and were the process to
occur in dead matter, such Avould doubtless be the case; but in the
living, it is different. The pressure acts more at one point than at the
others ; and that point on which it is as it were concentrated, is usually,
as already stated, towards the external surface. There the dose of
pressure is increased ; more than the absorbents are implicated in the
result, the vascular system is roused, true inflammation is induced,
ulceration follows, and by its crumbling agency the parts intervening
between the pus and the external surface are gradually removed ; at
each step the matter becoming more and more superficial. The orivay, the redundant
discharge gently removed, a fresh portion of lint laid on, and the oiled-
silk re-adjusted ; Avith a slight retentive bandaging if necessary ? The
ansAver to such question is—as seldom as possible ; just as frequently
as cleanliness demands, and no oftener. When the discharge is seen
soaking through the dressing, and beginning to drain away, renewal is
had recourse to; for not only are the circumstances filthy, and as such
affecting injuriously not only the patient but those around ; but besides,
the discharge, becoming subject to chemical change, groAvs irritant, and
may induce degeneration of an inflammatory type. There is then a
necessity for change ; but until such necessity occur, let no change be
made ; inasmuch as it cannot be effected, however delicately and dex-
terously, Avithout some injury being done to the tender surface by the
admission of atmospheric influence, as Avell as by rude mechanical con-
tact ; and by the oft repetition of this, again—from a cause directly
opposite to the preceding—inflammatory degeneration may be induced.
The " nimia diligentia" of surgery is fraught with manifold injury; and
is an error against which the junior practitioner should especially guard.
In practical surgery, nothing, hoAvever simple in itself it may appear,
should be done Avithout a good and substantial reason.
Another error, at least equally pernicious with too frequent dressing,
is an affected nicety in making the change of application; not only
Aviping aAvay the redundancy of discharge, but insisting on a perfectly
clean abstergence of the surface of the sore itself, till it look pretty and
red ; washing, sponging, rubbing, irrigating ; tlwarting Nature in one
of her most beneficial acts ; taking away, clumsily and rudely, the best
protection of the tender surface ; invoking inflammatory action, or ten-
dency thereto, with consequent degeneration of the sore. At each
dressing, Avipe gently away the pus from the surrounding integument,
but do not interfere Avith that which covers and protects the granu-
lations ; your dressing is subsidiary to this, and ought not to supersede
it. The means whereby the cleansing is effected are also a matter of
some moment. Usually, it is by a sponge ; but this is likely to prove
injurious, especially in the Avards of an hospital. A sponge is a thing
of some value, in the eyes of a patient or nurse, and not to be lightly
parted with. It is used not for one patient only, but for many, or all.
It becomes soaked with discharge, of various kinds; it is hastily and
imperfectly cleansed after each employment, and ere its course is run
can hardly fail to have been the means of conveying noxious matter to
previously healthy sores, inducing their degeneration, and perhaps
exciting the serious complication of erysipelas. Instead of sponge
ON ULCERS.
183
therefore, especially in hospital practice, let fine tow, lint, or soft linen
rag, be used as the abstergent agent; a thing of no value, and Avhich
consequently may be burnt as soon as used, and have no opportunity of
carrying contamination. And, generally speaking, the basin of cold
water, usually in attendance during the dressing, may be well dispensed
with ; dry and gentle wiping of the surrounding skin, leaving the actual
sore untouched, is all that is required ; more is not only unnecessary,
but tolerably certain to prove injurious; it belongs to the " nimia dili-
gentia."
But our attention must not be entirely engrossed Avith the part. In
all classes of ulcers, the state of the system must be constantly regarded.
As this deteriorates, so will the sore ; and vice versa ; indeed, a glance
at the character of a sore is one of the best means of ascertaining the
condition of the system; the ulcer telling as truthfully as the tongue,
pulse, or countenance. In the treatment of the simple healthy sore, it
is plainly our duty, therefore, with a vieAv to the ulcer retaining its
healthy character, until cicatrization be satisfactorily completed, to
rectify error in the system, if such exist, and maintain it in a sound
condition. The prime vie will especially claim our attention; cleansing
away noxious matter by purgatives, amending secretion by alteratives,
increasing tone by the suitable remedies, and directing especial regard
to the suitableness of regimen.
The tendency of the simple sore, unless Avhen over-stimulated either
by accidental external injury or by malapraxis, is toAvards the second
class, as already stated; and the prominent signs of change are to be
found in ibe granulations, which become paler, taller, less sensitive and
vascular, over-shooting the level of the surrounding skin; according
to the common phrase, they are exuwerbant. This coming change is to
be met by a corresponding alteration in the treatment; the Avater-dressing
being medicated, so as, by exerting more or less of a stimulant quality,
vigour may be duly maintained in the part and degeneration prevented.
When the process of cicatrization is by any cause long delayed, Iioav-
ever, the deterioration often does occur, in spite of our best efforts to
the contrary. And so long as the exuberant granulations remain above
the surrounding level, no progress can be made; for unless the old
skin and granulating surface be on the same level, or nearly so, the
neAV cuticular formation does not advance. The exuberance must be
brought doAvn : and for this purpose many remedies are in use. Es-
charotics may be employed ; nitrate of silver, or sulphate of copper;
the effect hoAvever is painful, not ahvays easily limited so as to save the
pellicle already formed, and not unlikely to be folloAved by over-action ;
undoing the granulating matter, by ulceration established afresh. Dry
pressure is in all respects preferable; less painful; Avith ordinary care
easily limited to the part desired ; and not likely to exceed in its effect
on the vascular system. A portion of lint or charpie is neatly laid oyer
the sprouting granulations, carefully avoiding the surrounding pellicle
of new skin—therefore ahvays rather too small than too large—and if
we wish to have the tender margins especially protected, we may cover
them with thin pledgets of fine lint spread Avith simple Avax ointment.
This dressing is retained by a few turns of a bandage ; not very tightly
181
PRINCIPLES OF SURGERY.
applied, hoAvever, for the intention is not to induce vascular action
sufficient to cause ulcerative disintegration, but merely such an amount
of pressure as shall suffice to occasion absorption of the granulations,
with a sthenic augmentation of vascular action around—far short of
true inflammation. It is plain therefore that care is necessary not only
in the adaptation of the compress, but also in the application of the
retentive bandage; lest either or both induce a greater result than is
suited to the object in vieAv. A few hours' use of a gentle compress
will sometimes suffice ; in all cases, the dressing should be early un-
done, that it may be desisted from so soon as the desired result has
been obtained ; and then—granulations and skin being once more on a
level—the simple protective dressing is resumed, and the cicatrization
proceeds afresh. In certain situations, as the neck, the application of
pressure may be inconvenient or altogether impracticable ; under such
circumstances, an escharotic is to be used gently.
2. The Weak Sore.—This is usually the result of the preceding;
when, from any cause, local or constitutional, cicatrization has been
delayed, and debility has usurped the place of sufficiency of action.
The granulations are larger and less numerous than in the healthy sore ;
much paler, of a faint pink, or yelloAvish hue ; taller, not of a decidedly
conical form, and bulbous rather than pointed at the apex; less firm,
and as if dimly translucent; little sensitive, bearing to be rubbed almost
with impunity ; less vascular, emitting blood but sparingly unless rudely
handled ; and the blood which does Aoav has often more of the venous
than of the arterial character. In truth they are imperfectly organized.
The discharge is pale and thin, the serum greatly predominating over
the solid particles ; there is but little fibrin, Avhether going to waste as
pus, or going to repair, as granulations. The general character of the
surface is pale, flabby, and elevate* above the surrounding integument.
This is often the seat of passive congestion, and sometimes of a serous
effusion folloAving thereon; consequently it is of a blue or livid tint,
soft and someAvhat SAVoln, though still beloAv the level of the granu-
lations ; often its free margin is overlaid by a bending over of the tall
granulating mass ; and the surface of the latter not unfrequently parts
with the granulated character, becoming uniform and villous in its
appearance.
When the sore has been the seat of frequent change; ulcerating,
because inflamed, one day ; granulating avcII the second, and Aveakly
on the third ; the granulations coming and going, as it were ; it is not
uncommon to find the sore permanently assuming the Aveak character,
and its integumental margins, having lost their support by the previous
accessions of ulceration, are more or less inverted, as well as unusually
dark by livid discolouration. This undermining and consequent inver-
sion of the margin, is rather to be regarded as an accidental than as one
of the ordinary characteristics of the Aveak sore. Sometimes the under-
mining is extensive at one or more points, matter accumulating there,
unless when removed by pressure; and a probe passes readily into the
cavity, which is marked by swelling and blueness of the integument.
All in short evinces a want of sthenic action; and this may either
depend upon local circumstances, as already shown, or be but one
ON ULCERS.
185
indication among others of a feeble system. No sore of large extent
can escape degeneration into this form ; it is the inevitable result of
protracted cicatrization. A sore situated on the lower extremities—far
from the centre of circulation, its venous return often if not habitually
opposed, and all circumstances very favourable to passive congestion—
is extremely prone to become Aveak. And not unfrequently such de-
generation would seem to be connected Avith atmospheric influence;
one day the majority of the ulcers in an hospital or Avard may shoAv a
healthy character; next day they may all be Aveak or othenvise deterio-
rated, with no cause assignable, excepting perhaps the occurrence of a
sudden and marked and unfavourable atmospheric change. Repeated
ulceration of the same part, is a plain indication of debility there ; and
it need not surprise us to find that such sores invariably tend toAvards
the weak character. Also, Avhenever the breach of surface has been
originally caused by injury Avhich entails debility of the surrounding
parts, that debility is certain soon to shoiv itself in the sore; as after
bruise and burn.
Treatment.—Prevention being better than cure, it will be our object
to prevent decline from the healthy condition, if circumstances place
this Avithin our poAver. The granulations getting pale, tall, and changed
both in form and number, Ave abandon the simple water dressing, and
have recourse to stimulants ; gentle at first, lest over-action be induced;
in avoiding one obstacle, we take, care not to encounter another still
more opposed to the healing process. The piece of lint, instead of
being steeped in plain tepid water, is saturated with a solution of a stimu-
lant nature, and reapplied in the ordinary way ; sulphate of zinc, nitrate
of silver, sulphate of copper, creosote, chloride of soda, are some of the
excitants more commonly employed. Of these that Avhich enjoys most
favour, and in our opinion with justice, is the sulphate of zinc—in the
form of lotion—Avhich may consist of six grains of the sulphate of zinc,
with two drachms of the compound spirit of lavender, and half a drachm
of the spirit of rosemary, mixed in five ounces and a half of water ; of
course the flavouring ingredients may be varied in their proportions, to
suit convenience or fancy. If this smart much on its first application,
it is to be diluted with tepid water; gradually diminishing the amount
of this, in proportion as increase of stimulus is required.^ It is Avell
however that we have a number of such remedies at our disposal; for
any one of them, used for a considerable period, loses its effect; and it
is better under such circumstances to shift from one kind of lotion to
another, than to increase the strength of the one originally employed.
At the same time, moderate bandaging is applied ; favouring, by its
mechanical support, venous return, and a normal state of the general
circulation in the part; affording also the salutary stimulus of uniform
gentle pressure ; and preventing the occurrence of passive congestion—
a sure forerunner, if not an attendant on debility. The fulfilment of
such indications by bandaging, carefully employed, is also plainly
applicable to the treatment of the first class of sore which has been long
open, and threatens in consequence to pass into the second. This with
the medicated Avater dressing, and d-e attention to the system, will in
many cases succeed in maintaining the characters of the first class, and
16*
186
PRINCIPLES OF SURGERY.
thereby much abbreviate the process of cure. And thus we find the
remedies suited to the cure of this second form of sore, to be the samo
as those calculated to prevent its occurrence ; differing only in degree.
Ointments Avere at one time much in vogue in the treatment of ulcers,
both of the simple and degenerate kind ; but are noAV almost entirely
superseded by the water-dressing, simple or medicated, which possesses
all the good qualities of the other, without any of the actual and possible
disadvantages.
Should the judicious use of stimulant lotions fail to repress the ten-
dency to exuberance of granulation, they are to be for a short time
superseded by the compress of dry lint; Avhen the level has been thus
restored—and often it may be Avell to continue the pressure until the
granulating surface is a little lower than the surrounding skin—their
use is resumed. And under such circumstances we seldom omit the
uniform and gentle bandaging, as an additional and well adapted means
of maintaining, due energy of action.
But local support is not alone sufficient. The general system re-
quires our aid, as well. Secretion and excretion, having been found
in order, or duly restored, nutritious regimen is enjoined; animal food,
wine, malt liquors; given Avith a freedom proportioned to the poAver
of digestion; and all sources of depressing influence are studiously
avoided.
3. The Scrofulous Sore.—This class of ulcer is weak almost from the
first; for it is only one indication, among others, of a system not only
decidedly weak, but of such debility as establishes a decidedly vicious
or cachectic state—that of scrofula. Such sores seldom occur singly,
but in clusters ; they are gregarious ; at first distinct from each other,
but ultimately becoming more or less confluent. The most frequent
sites are, the neck, shoulders, arms, hips, loAver limbs—especially in
the neighbourhood of the articulations. The sores extend more in
surface than in depth ; yet their origin is not in the skin, as most other
ulcers are, but in the sub-cutaneous cellular tissue. The commence-
ment is made there by tubercular deposit, causing induration and en-
largement, at first painless ; then perverted vascular action sets in, of a
higher grade than the merely nutritive, and the consequences are pain
in the infiltrated part, increase of swelling, and redness of the super-
imposed integument, Avith the other ordinary signs of the chronic
inflammatory process ; imperfect suppuration takes place ; the swelling
softens and pits on pressure; by and bye fluctuation is felt, and the
fluid is seen through the integument very much attenuated ; but there
is no regular pointing; almost the whole of the integument over the
suppurated and infiltrated part becomes thin, blue, and translucent; it
gives Avay partly by sloughing, partly by ulceration ; and through the
large, ragged, irregular aperture thus formed, the thin pus, with broken
down tubercular matter, and portions of sloughing cellular tissue, is
discharged. For some time no effort is made towards reparation; on
the contrary, the thinned and blue integument still farther ulcerates,
and the infiltrated tissue beneath still oozes away in the discharge.
The surface has no granulations, and is of a dirty gray hue, surrounded
by thin discoloured skin, undermined, inverted, and floating loosely
ON ULCERS.
187
on the subjacent parts. After a time, some parts of the infiltrated tis-
sue have been cleared away by disintegration or sloughing, and there
granulations begin to appear ; but they are of the weak kind, tall, pale,
and exuberant. A probe, used even with much gentleness, passes
readily through granulations into the boggy texture beneath, causing
little if any pain, and but slight effusion of blood ; or, following a super-
ficial course, it_ finds integument undermined, and a ready communi-
cation so established from sore to sore. Around the cluster, there is
usually a considerable amount of the products of the ordinary chronic
inflammatory process ; serum, and fibrinous effusion, the former much
predominating; and this greatly increases the amount of general SAvell-
ing, while it no doubt obstructs still farther all salutary effort towards
reparation. The system, originally in a bad state, is Avorse noAV ; sym-
pathizing much with the local disorder, and usually evincing more or
less intensely the ordinary signs of constitutional irritation ; at first,
during the inflammatory and softening process, there may have been an
effort toAvards sympathy of a sthenic kind ; irritative fever, however,
is more likely to occur than the inflammatory; and the ultimate result
is usually a hectic.
Such sores, if left to themselves, sometimes skin over, at least in
part; imperfect clearance of the tuberculated texture having probably
been effected by either ulceration or sloughing, or by both. But such
cicatrix is very unstable, and certain to be undone at no distant period,
disclosing a state of matters beneath not in the slightest degree amended.
It is blue, soft, spongy, and elevated ; whereas the true cicatrix is white,
firm, and depressed. It is but as " the green mantle of the standing
pool," Avhich only for a time obscures the filthiness beneath.
Treatment.—It need hardly be said that the more important part of
this is constitutional; attacking not one symptom of the disease, the
sore ; but the disease itself, the scrofula. • The nature of that treatment
need not be here repeated. Suffice it to say, that it must be steadily
and patiently persevered in, not only during the cure of the local affec-
tion, but long after ; otherwise immunity from speedy relapse can never
be expected. Indeed, the most difficult part of the treatment will in-
variably be found to consist in preventing return of the sores, but lately
healed ; resumption of the erect posture, exposure to cold, a blow,
excess in diet, too often suffice for early reproduction.
The local management-requires to be energetic, and at first severe.
Medicated lotions, ointments, poultices, will prove wholly unavailing
in this class of sore. There is an unsound foundation for the repara-
tive process, and that must be cleared away. The potassa fusa, in
solid substance, is inserted boldly into the infiltrated cellular tissue ; if
the integuments have not already given way, they will readily yield
before this; and then it is freely moved in various directions, so as to
destroy thoroughly not only the cellular tissue Avhere tuberculated, but
also the integuments where thinned, blue, undermined, and obviously
incapable of recovery. Also, it is made to pass from sore to sore, sub-
cutaneously; and, used somewhat as if a cutting instrument, it effects
destruction of the intervening integument. Ulcer after ulcer is thus
treated until not only is each cleared of the dead and dying textures—
188
PRINCIPLES OF SURGERY.
all these being by the escharotic at once converted into complete
sphacelus—but the burrowing inter-communications are also freely ex-
posed, and similarly freed from their unsound parts. It is, avowedly,
a painful process, but most effectual; indeed, according to my expe-
rience, altogether indispensable towards obtaining a satisfactory cure.
It should be done determinedly—rapidly yet carefully; and it is better to
overtake the Avhole at once, than to temporize Avith partial instalments.
The surrounding parts during the operation are protected by oil; and
aftenvards, oil is freely applied to the cauterized part, in order to assuage
the pain, and prevent unnecessary extension of the escharotic effect;
for we usually do not desist from the use of the potass, until tolerably
certain that it has reached all the doomed texture ; but little increase
of the immediate slough, therefore, is desirable. Dark bloody discharge
oozes out during the application, containing a considerable quantity of
the escharotic in solution; this is carefully and constantly Aviped away
from the integument on Avhich it comes. After such discharge has
ceased, the whole part is covered Avith a poultice ; and this dressing is
continued until the slough has separated, disclosing a healthy granu-
lating surface beneath—firm, red, vascular, and sensitive; then the
water-dressing is assumed, and the local management afterwards con-
ducted as for the first class of sore, into Avhich the original affection has
in truth been happily converted. On separation of the slough, how-
ever, should the appearance of the subjacent part not be altogether
satisfactory—from insufficiency of the escharotic application, or from
renewal of the tubercular deposit—more probably from the former—the
potass is to be unhesitatingly reapplied, to such an extent as may be
deemed necessary. Also reapplication comes to be expedient—and
that not unfrequently—after reparation has someAvhat advanced ; on the
slough's separation, a healthy granulating surface appeared, and all
Avent on favourably for a time ; but then came delay, then arrest, and
afterwards degeneration ; the part threatening to return to its former
unsound condition. Early use of the potass, to a comparatively limited
extent, arrests the degeneration ; and in a few days the reparative pro-
cess is vigorously re-established. But in order to avoid such repeti-
tions, as far as possible, let the first application of the potass be deter-
mined and complete ; rather destroying too much than too little; and
never for a day let the attention be diverted from the constitutional
management. After cicatrization, it is to maintenance of general treat-
ment that we must look for prevention of relapse ; along Avith uniform
support afforded to the part, more especially Avhen this is in the lower
limb. Bandaging—or what is better, a laced stocking, with its part
more slackly applied than the lower, in order to obviate congestion from
venous obstruction—is under such circumstances a most valuable means
of prophylaxis. And be it remembered that all cicatrices, more espe-
cially when extensive, and the result of sores defective in action, re-
quire much care, being by reason of recent and imperfect organism
very liable to be undone by re-accession of ulceration.
4. The Indolent Sore.—Perhaps this is the most common of all
ulcers; it is most frequently found in the lower extremities, and at a
somewhat advanced age. It is invariably of secondary formation; this
ON ULCERS.
189
Condition of confirmed deficiency of both action and poAver having
supervened on a state of matters Avidely different. The sore may have
been at first healthy, then inflamed, perhaps thereafter irritable, then
weak, and ultimately indolent; merely in consequence of cicatrization
having been often opposed and long delayed, by the situation of the
sore, and by the accidents to which it has been exposed. A Aveak
system is often found co-existent, and may have had some share in the
induction of the local apathy. From Avhat has just been said, it can be
readily understood hoAV such sores should be most frequently found in
the legs of the labouring classes ; so frequently indeed, as to almost
warrant a statement of the indolent sore being peculiar to that important
class of the community.
The surface is excavated, smooth, glossy, pale, usually altogether
void of granulation, sometimes sparsely studded by a feeble attempt at
such formation. The discharge is thin and serous ; containing but little
fibrin, and the little Avhich is effused passes off either in the form of pus
globules, or in flaky masses not even so highly organized. The sur-
rounding integument is both SAvoln and condensed, and discoloured by
passive congestion, superinduced in the ordinary interstitial products
of the chronic inflammatory process ; and that Avhich constitutes the
margin of the sore is much elevated above the raAV surface, round,
dense, Avhite, callous ; in truth this is the most striking characteristic of
the sore ; Avhich not unfrequently looks like a piece of pale mucous
membrane, set in a dense and high ring of cartilage. It need hardly
be said that such margins are not undermined, and neither everted nor
JnTcrted ; but raised abruptly, a firm solid structure, the result of re-
peated accessions of the inflammatory process of a Ioav grade and chronic
character. Both sore and margins are comparatively insensible.
But usually the sore does not present the characters just enumerated,
when first brought under our notice. So long as it is merely an indo-
lent ulcer, the patient suffers little pain or other uneasiness, and con-
tinues his wonted avocations. But he receives a bloAV on the part, or
is exposed to wet and cold, or other exciting cause of the inflammatory
process is applied ; inflammation is induced in and around the sore ;
he can work no longer, the erect position even is difficult, and he then
applies for relief. Under such circumstances, the ordinary characters
of the indolent class are seen, as it were, through an inflammatory
medium. The surrounding skin is red, more swoln, painful, and even
the callous margins are reddening ; the raw surface is still low and
void of granulation, but red and softening ; the discharge is still thin,
but bloody, and mixed with more or less disintegrated texture—for
ulceration is soon re-establised. By and bye, the part, being low in
power, is overborne by the increased action; the margins as well as
surface of the sore become converted into a slough, and as such are
gradually detached. On separation of the slough, we expect to find a
healthy surface beneath, so soon as the inflammatory and ulcerative
processes shall have subsided. # .
The Mucous Sore, of some authors, is merely a. variety of the indo-
lent class, in which the raw surface, by reason of long persistence, has
been thoroughly converted into a resemblance of mucous tissue ; pale-
190
PRINCIPLES OF SURGERY.
red, smooth, and villous ; shining, as if varnished ; with a limpid, quasi-
mucous discharge.
Treatment of the indolent class of sores. As just stated, the part is
usually presented in an inflamed state. The patient is put to bed, and
a poultice applied to the sore and its vicinity. The tongue Avill be
found heavily coated, and other plain indications of great derangement
in the prime vie will not be wanting ; an active purge, repeated if ne-
cessary, is therefore highly expedient. Low diet is enjoined ; and if
this, Avith the action on the bowels, be not quite equal to allay the in-
flammatory fever, which is likely to be more or less developed, anti-
mony may be also exhibited. Thus, in a day or tAvo—according to
the ordinary phrase, a cleansing of the sore is obtained; that is, the
slough, having become completed, separates by ulceration ; the vascu-
lar action subsides from the suppurative and ulcerative grade—remain-
ing in a more subdued, but yet exalted form, favourable to plastic
effort; and, consequently, on detachment of the slough, a healthy sur-
face is usually found beneath, demanding the mode of treatment
suitable to the first class of sore.
When the sore is presented in the simply indolent state, two modes
of treatment are in our option. First, we may imitate the process
whereby Nature rids the part of its incubus ; by induction of the inflam-
matory process. This may only induce ulceration of the previously
callous surface, giving the granulating action on subsidence of the in-
flammatory ; or going by a step further, it may more closely imitate
Nature, converting all the parts which evince the indolent character
into a slough, leaving the reparative action to follow on fcbat slough's
separation. For this purpose, a blister is probably the most conve;
nient stimulus. Usually it is applied so as to produce the major effect;
and after the requisite amount of inflammation has been induced, the
treatment is the same as that already advised under similar circum-
stances of spontaneous origin. The only objection to this mode of
treatment is that it is painful, and brings some hazard of inducing more
action, as regards both extent and intensity, than is at all desirable ; for
be it remembered, both part and system are usually in such a state as
to be both prone to the assumption of the inflammatory process, and
unfavourable to its control. We may seldom fail thus to change the
character of the sore ; but occasionally—perhaps not unfrequently—it
may be at the cost of establishing a worse disease, erysipelas. Be-
sides, even supposing that such accident do not ensue, undoubtedly
the first effect is to enlarge the raw surface ; it is a larger though abet-
ter sore that we obtain ; and it is not improbable that ere that wide
space can be brought entirely to close, it may have degenerated, in
spite of our best efforts to the contrary, into the Aveak, or perhaps once
more into the indolent form. On the whole, therefore, as a general
practice, the other mode of treatment is preferable.
Second.—By continued pressure the surrounding elevation is to be
undone, and the villous surface changed into a granulating sore. The
first part of the manipulations is, to support the whole oAhe limb be-
low the ulcerated point by moderate and uniform bandaging ; if this be
neglected, congestion must ensue, and more serious consequences are
ON ULCERS.
191
not unlikely to follow thereon. Then a strip of the common adhesive
plaster, about one inch in breadth, or rather less, is applied with tole-
rable tightness over the lower part of the sore ; crossing the ends over
this, the centre of the strip having been applied to the opposite point
ot the limb. Plaster after plaster is thus adjusted, until we have in-
vested not only the whole open surface, but also a little of the unbroken
skin both above and below. The bandaging, which had stopped to
admit of the application of the plaster, is then continued, covering the
whole limb, from the very distal extremity to about a hand-breadth
above the seat of the ulcer. The limb is then placed in an elevated
position, and for some hours this, as well as the general recumbent
posture, is strictly maintained. A feeling of constriction, sometimes
amounting to actual pain, is usually complained of; but seldom lasts
long; and still more rarely does it by persistence render an undoing of
the dressing necessary ; it is sufficiently met by rest and the elevated
position of the part; or, should this fail, affusion of cold water will suf-
fice to restore comfort. After two days—not earlier, unless symptoms
of inordinate vascular action have manifested themselves—the bandage
is undone ; a grooved director is insinuated beneath the plaster, at the
point opposite to the ulcer; on this the strap is cut; the dressing is then
gently removed; and according to the change which has been effected
in the sore, is the same dressing repeated, or another substituted more
suited to the characters Avhich the sore noAV presents. When the sore
is large and discharge profuse, a slit may be made in each strap,
where it crosses over the ulcer, in order to prevent purulent accumu-
lation.
By the continued pressure on the callous margins, absorption is in-
stituted there—partly interstitial, partly continuous ; and thus they are
gradually brought doAvn from their undue exaltation of level. By the
same agent acting on the villous surface, this is broken up by disin-
tegration ; for pressure which only causes absorption in an unbroken
part, is equal to the induction of ulceration in that Avhich is depived
of integumental protection ; by and bye, this destructive action ceases,
the part becoming habituated to the stimulus, Avhich is gradually lessen-
ing by yielding of the dressing ; granulation succeeds ; and thus the raw
surface mounting up, Avhile the surrounding integument is descending,
the equal level requisite for cicatrization is gradually approached. For
the stimulus continues to act both on the skin and sore ; causing ab-
sorption in the one, and maintaining vigour of vascular action in the
other. As formerly explained, pressure in a slight dose, excites the
absorbents chiefly ; in a greater, arouses vascular action of a sthenic
kind, short of true inflammation ; a still larger dose reaches the true in-
flammatory acme, bringing suppuration and ulceration. Here the same
dose is applied to both margins and sore ; but the latter is less tolerant
than the former; and in regard to the latter the same pressure is prac-
tically equal to a higher dose, than that which is operating on the mar-
gin. Hence Ave have only absorption in the one, and in the other vas-
cular excitement of a sthenic type.
Besides, the mechanical effect of the circular band, is to draw toge-
ther the sound parts on the sore, and thus greatly to favour not the
192
PRINCIPLES OF SURGERY.
least portion of the cicatrizing process—that is the centripetal move-
ment of the original tissues.
Sometimes, Avhen the edges are very high, and the sore deep and
small, the plaster reaches only the' margins at first, the raw surface
escaping by their interposition; a certain amount of salutary stimulus
is nevertheless conveyed to the latter; and on subsidence of the skin
the pressure comes to act on both in the usual manner.
In all cases, it is very apparent—by regard to the modus operandi
on the raw surface—that the amount of pressure must be carefully regu-
lated. At first tolerably severe, to induce absorption and disintegra-
tion ; afterwards more moderate, lest the vascular action be overdone,
and the reparative effort on the raw surface be opposed rather than ad-
vanced. Much in the same Avay as Ave found it advisable to regulate
pressure, gradually diminishing its amount, in the treatment of sinus.
At first we Avant change of structure, and an aroused action ; after-
wards a maintenance of action, neither too high nor too low, but suffi-
cient for the purpose of progressive repair.
The dangers plainly are, over-action, and strangulation of the limb—
even although the latter be provided against by previous careful ban-
daging. Both Avill be prevented by a very simple proceeding; making
a section of the mass of plaster, after it has firmed on the part, on a
grooved director introduced at the point opposite to the sore. This is
sufficient to relieve constriction, and to moderate pressure ; the bene-
ficial effects of pressure are not foregone, Avhile danger is obviated ; and
besides, the resilience of the plaster to the opposite point from that cut
plainly augments, and not inconsiderably, the important centripetal
action of the integument, and cellular tissue around the sore. This,
therefore, apparently a trifling and perhaps detracting circumstance, ia
in truth an important and corroborating addition to the manipulation;
and ought seldom to be omitted. The strap is first firmly applied; then
alloAved a few minutes to consolidate, and tightly embrace the limb;
and then the section is made.
Another advantage of this second mode of treatment is, that although
more progress is likely to be made in the recumbent posture, yet it is
not essential that this should be uniformly maintained. For a few hours
after adjustment of the dressing, rest is indispensable ; but afterwards
the erect posture may be resumed, and Avonted avocations thereAvith—
a point often of the utmost consequence to the patient; such resumption
may delay the cure, but will not prevent it. Sometimes this mode of
dressing may be continued, on almost each occasion less tightly ap-
plied ; but very frequently the character of the sore changes so very
decidedly for the better, after one or two applications, as to call for
corresponding change of treatment to the simple dressing suited to the
simple and healthy sore.
Throughout the cure, the system is duly attended to; the diet is
generous; and it may be that tonics and even stimuli become expedient;
for little good can be expected to follow on the most skilful treatment
of the part, unless the general frame be provided with sufficient power
to maintain the reparative action. In the opinion of some, small doses
of opium—half a grain night and morning—are of use in maintaining
ON ULCERS.
193
energy of the capillary circulation, more especially when the patient ia
far advanced in years.
After cicatrization, local support, by bandaging or a laced stocking,
is not to be omitted ; otherwise relapse is but too probable. A small
circular aperture appears near the centre of the cicatrix, as if made by
a pin's point; this rapidly enlarges ; and the sore may assume the cha-
racters either again of the indolent or of some other variety.
5. The Irritable Sire.—This is an example of irritation supervening
on the products of inflammation ; usually of secondary occurrence • and
the result of accident, of malapraxis, or of a depraved state of sys'tem.
The sore is almost invariably superficial, not penetrating more deeply
than the true skin ; in fact, this texture may be said to be the peculiar
site of this class of ulcer ; and this circumstance may in part account
for the great sensibility of the sore. The surface is unequal, deeper at
some points than others; it is. void of granulation, and either of an
angry dark-red fleshy hue, or covered with a grayish film of tenacious
aplastic fibrin; sometimes this covering only partially invests the sur-
face, which then shoAvs both the red and gray appearances. The edges
are thin, serrated, and everted ; of a red angry hue, and sometimes
studded with brightly florid points as if of arterial blood. The sur-
rounding skin is slightly swoln, and also of a dull red colour, being in
a state of passive congestion ; or perhaps, rather, not yet recovered from
the chronic inflammatory process. The discharge is thin, acrid, bloody,
often mingled Avith solid matter—either recently effused, or from disin-
tegration of the old. Pain is constant, ahvays considerable, often ex-
cessive ; the slightest interference with the acutely sensible surface is
followed by intense burning pain, and by a copious Aoav of blood,
usually of a dark grumous character ; as if the injury were resented, in-
stead of being merely acknowledged as in the healthy sore. Generally
an irritable state of system precedes and accompanies this state of the
part; but even when no such predisposition exists, that morbid condi-
tion of system is almost certain to occur—an example of constitutional
induced by local irritation. And along with the ordinary symptoms of
the constitutional form—more especially restlessness, want of sleep, loss
of appetite, emaciation, general disorder of secretion—there is often a
remarkable peevishness of temper unhappily combined.
This kind of sore is liable to occur any where ; more especially if it
folloAV on eruption, as it very frequently does; but its most frequent
locality is on the lower limbs, on the shin, and near or over the ankle.
It is not unlikely to pass into the next class of ulcer ; an example of
what is not unfrequent—irritation inducing inflammation.
Treatment.—This is partly, and sometimes mainly, constitutional;
the predisposing, if not the exciting cause is in many cases to be found
in the system, and must be opposed by the suitable remedies ; with this
vieiv the primse v'vx, and general secretion, will especially claim our
attentive regard. In other respects, the treatment suitable to constitu-
tional irritation is maintained, along with the local management. This
consists of rest, quietude, elevation and relaxation of the part; and
such applications are made use of as Ave formerly saw to be most ad-
visable in cases of irritation. Of these, none are so generally useful
17
194
PRINCIPLES OF SURGERY.
as the nitrate of silver; applied lightly to the raw surface ; with some
intensity to the margins, so as to produce a slightly escharotic effect
there, and bring them into a form more suitable for the commencement
of cicatrization ; and pencilled, again lightly, over the surrounding skin,
where swoln and discoloured, as merely to blacken this, and obtain
the sedative and purely antiphlogistic effect. A temporary increase of
pain usually follows in the sore, but soon passes away, on the applica-
tion of a soft light poultice, or the hot Avater-dressing; and this epithem
is continued until the re-application of the nitrate ; which may be daily,
or only on each alternate day, according to the effect produced. Under
this treatment, amendment is often rapid and satisfactory ; pain dimi-
nishing, and soon ceasing to be inordinate, the margins losing their
irritable characteristics, and the raAV surface beginning to be studded
with healthy granulations; then the ordinary simple treatment is assumed.
But success is not invariable ; the pain may be permanently increased
by the application, and the sore either becomes more and more irritable,
or threatens to pass into the inflimed. In such circumstances more
simple sedative means must be applied to the sore, the pencilling by
nitrate of silver being still continued hoAvever to the surrounding in-
tegument. An aqueous solution of opium may be used, five grains to
the ounce; conium, hyoscyamus, belladonna, or aconite, cautiously;
and sometimes good effects are produced by a Aveak nitric-acid lotion
—from two to five drops to the ounce of distilled water. When the
sore is secondary to cutaneous eruption, a weak solution of arsenic is
often very beneficial; and in such cases it is Avell to combine the inter-
nal Avith the local use of this remedy. But in my opinion, neither
arsenic nor nitric acid are suitable as early applications to this kind of
sore ; they are apt to stimulate instead of soothing ; and should only be
had recourse to as alteratives, after the characters of the sore have been
somewhat modified by the previous use of more appropriate, because
more truly sedative remedies. If even these fail to relieve, much bene-
fit will sometimes follow continued exposure of the part to steam of hot
water, of as high a temperature as can be conveniently borne. Should
the light application of the nitrate of silver fail to remove congestion
from the surrounding skin, leeches or punctures may sometimes, though
rarely, be required.
On the whole, as already stated, the most trustAvorthy and generally
applicable local remedy is the nitrate of silver ; used not oftener than
daily, and usually but once in the forty-eight hours ; applied with great
lightness to the raw surface and surrounding skin, so as only to produce
its slightest effect—the very opposite of escharotic—sedative, anodyne,
and protective by the formation of an investing pellicle on the sore;
pressed firmly only on the margins ; and they too come to be but ten-
derly dealt Avith, so soon as they have undergone a favourable change.
P._ The Inflamed Sore.—This presents the ordinary characters of ad-
vancing ulceration, with accompanying inflammatory action ; and, as
can be readily understood, is the most common original form of ulcer.
Very often, however, it is of secondary occurrence ; for over-stimulation
is not unlikely to happen in the treatment of ulcer of a healthy, or even
of a sluggish kind. The raw surface is gradually disintegrating; and
ON ULCERS.
195
instead of contracting, steadily enlarges ; showing no granulations, but
a soft, raAv, pulpy substance ; and emitting a profuse ill-formed pus,
mingled with the ulcerative debris. The margins are swoln, red, hot,
tense and painful; and so is the surrounding integument. The erect
posture^ and motion increase the pain ; the system is more or less in-
volved in febrile disturbance of the inflammatory type ; and the prima?
viae are usually found in marked disorder. Not unfrequently, the action
running high, while local poAver is weak, sloughing takes place, more
or less extensively ; as already noticed in regard to inflammation super-
vening on the Indolent variety of sore.
The treatment consists of moderate antiphlogistics. Rest, relaxation,
elevated position, fomentation, poultice, hot water-dressing, antiphlo-
gistic regimen, purgatives, antimonials. Sometimes it is necessary to
draw blood locally; and this may be done by leeches or punctures.
The former are sometimes placed on the sore itself, Avith a good effect;
and this practice may also occasionally prove beneficial in the irritable
sore, when folloAving on the inflamed, and surrounded by considerable
and someAvhat active congestion. Punctures are preferable, however,
in the integument; for leeches there are apt by their own irritation to
induce a spreading of the inflammatory process, of an erysipelatous
kind ; or the bites may themselves assume the ulcerative action, and
so extend the original disease. Let not however, the antiphlogistics,
even when moderate, be continued one moment longer than is abso-
lutely necessary, otherwise degeneration into the weak sore is speedy
and certain: let it be always remembered, that a part once truly in-
flamed, is ever after defective in vital poAver.
7. The Sloughing Sore.—This differs from the sloughing state which
not unfrequently attends on the simply inflamed, in being not a casualty
and temporary, but an inherent characteristic of the disease—Avhich
usually begins with the formation of a slough, and continues to enlarge
by repetition of the same process; the result of local vascular excite-
ment, occurring not only in a part but in a system of diminished poiver.
Such action is in itself not great, and in a sound texture would proba-
bly lead to no higher result than simple exudation, but in a worn frame
and weak part vital power is almost instantly overborne, and almost the
first indication of the action's presence is supersedence of vital by
chemical change. Thus the inflammatory process instituted in the
sexual organs of ill-clothed, ill-fed, intemperate, abandoned prostitutes,
living in the densest and filthiest parts of dense and filthy cities, is very apt
to produce this kind of sore. Here the local and general debility exists
before the application of the exciting cause. But the relation may be
reversed; the cause may be capable of exerting such a depressing
influence on both system and part rapidly, that the inflammatory process
which it exoites very speedily terminates in gangrene ; as happens in
inoculation of certain poisons ; that of venomous snakes; of diseased
animals, producing " malignant pustule ;" of certain forms of venereal
virus, establishing the most formidable kind of that disease.
Or the inflammatory process may itself induce a change in the part
affected, inimical to power, and favourable to predominance of action.
196
PRINCIPLES OF SURGERY.
Thus, a sore on the penis may be of a simple acute nature ; paraphi-
mosis ensues, in consequence of the surrounding inflammatory swelling;
change of relative position is neglected, consolidation takes place, and
then attempts at reduction are unsuccessful; the constriction is neither
so great nor so complete as to produce complete sphacelus of the whole
glans, but it is sufficient to establish slough after slough on the breach
of surface. And this is an example of Avhat may be termed the secon-
dary sloughing sore; not commencing with a slough; but an ulcer,
passing into that condition, and remaining so degenerated.
The originating slough is sometimes dry, sometimes moist; according
to the rapidity with which the destructive process has advanced.
Usually great humidity is one of the most characteristic features of the
sore. When dry, the case may be termed a chronic form of the disease,
by far the less frequent in occurrence. Sometimes, after a dry com-
mencement has been made, a rapid transition takes place into the humid
form ; the discharge commencing Avhen the first slough begins to sepa-
rate, and soon becoming profuse. Much pain attends ; whatever may
have been the previous state of the system, there is soon much consti-
tutional irritation ; and at the same time the primae viae—by loaded
tongue, foetid breath, &c.—generally indicate very prominent disorder.
Not unfrequently—as in the malignant pustule—a'vesicular or pustular
condition of the surface briefly precedes .the actual death of the part.
A superficial slough having fairly formed, it begins to be detached.
Its edges loosen, and expose the subjacent parts ; but these instead of
showing the red fleshy granulations of repair, or even the angry aspect
advancing ulceration, disclose but a new formation of slough, soft and
tawny ; and thus gangrene upon gangrene may succeed—in strata, as
it were—until the part has been frightfully mutilated, and the system
brought into the most alarming disorder. The surface is generally of
an ashy hue ; sometimes inflated by gaseous extrication; sometimes
darkened by commixture with a grumous bloody serum. The dis-
charge is thin, foetid, sanious, usually very profuse, giving the charac-
teristic humidity, and mingled with putrid solids partially dissolved.
Not unfrequently hemorrhage takes place ; profuse ; arterial or venous,
more frequently the former; the sloughing, unpreceded by interstitial
and plastic deposit, having opened a vessel of considerable size and
activity. The result of this bleeding is sometimes beneficial, some-
times highly hazardous ; the former, if it affect only the part, critically
resolving the action ; the latter, if it effect not only the part but the
system, depressing still further the powers of life which are already too
low ; fatal results from this cause have not been unfrequent.
There is every reason to believe that this form of malady is con-
tagious ; that the secretion from a sore of this kind applied to a healthy
ulcer, or perhaps even to an unbroken portion of skin, may induce a
state similar to the original.
8. The Phagedenic Sore.—This is a spreading ulcer; destruction
advancing more determinedly than in simple ulceration, however acute;
but still by molecules, not by masses as in sloughing. It results from
a somewhat similar conjunction of circumstances with the preceding;
ON ULCERS.
197
local action exceeding local power, and usually attended with debility
as well as irritability of the system. Two forms occur; the acute and
chronic.
The acute is usually a sore of irregular form ; with margins abrupt
and someAvhat ragged ; and these as well as the integument to some
distance around, the seat of active vascular action, are red and slightly
swoln. The sensation is of a sharp burning heat. The raAv surface is
of a brownish hue, totally void of any thing like granulations, of uneven
depth, and in many places presenting the appearance as if gnawed by
the tooth of a small animal. The system suffers severely; and the
form of disorder is that of constitutional irritation.
The chronic variety is less painful, less inflamed, less rapid, darker
in hue, with the gnaAved appearance usually more distinct, commonly
surrounded by considerable induration, and often spreading at one
aspect, Avhile slowly cicatrizing at the opposite ; withal the ' constitu-
tional disturbance is less severe.
9. The Sloughing Phagedena.—The acute phagedaenic sore seldom
persists in a distinct form ; much more frequently it is associated with
the sloughing, constituting sloughing-phagedaena. Commencement
may be made by either. If the phagedaena have preceded, the sore
becomes lighter in colour, with margins less distinct, temporary diminu-
tion of discharge, and perhaps a lull in the pain; a thin slough forms;
this begins to separate, discharge again becomes profuse, and on sepa-
ration having someAvhat advanced either a second slough is seen being
formed, or the part is found yielding before re-accession of phagedsena.
Sometimes the alternation of slough and ulcer is tolerably regular ; in
other cases one or other form of destruction may have the predominance.
The constitutional disturbance.is at least equally severe as in either the
sloughing or acute phagedaena, uncombined; indeed, very frequently
both part and system suffer more in the combined form, than in either
singly. The combined is less frequently original, than either of the
separate forms.
Familiar examples of the sloughing ulcer may be found in the malig-
nant pustule, and the sloughing sore of the penis; of the phagedaenic,
in the lupus of the face, and the phagedaenic form of the venereal dis-
ease ; of the -sloughing-phagedaena, in the hospital gangrene or sore,
and cancrum oris. In all these varieties, but more especially the last,
the discharge is remarkably foetid; and so strikingly peculiar is the
foetor as to constitute one of the most prominent characters of the dis-
ease ; poisoning thoroughly the atmosphere of even a large apartment,
and felt oppressive at a great distance.
Treatment.—The treatment of these three classes, being in most
respects identical, has been reserved till now. It is both constitutional
and local. The primse viae almost invariably showing signs of oppres-
sion, a purgative, not over active, is exhibited; and some antimonial
may be at the same time given, should there seem any effort towards a
sthenic form in the constitutional disorder ; if there be, it will only be
at the commencement, for very soon irritation is the decided type.
When the tongue begins to clean, and the patient looks lightened by
the evacuation, then the treatment pecuhar to constitutional irritation
17*
198
PRINCIPLES OF SURGERY.
should come into play ; and the best medicine in my experience, under
such circumstances, is the pulv. ipecac, c. opio, in closes of ten grains,
or thereby, given three times a-day: it relieves the secretions, assuages
local pain and general irritation, brings doAvn the pulse, gives sleep,
and obviously exerts a most beneficial influence on the local disease;
and should this by persistence demand repetition of painful remedies,
it is well to give an additional dose of the powder at each such repeti-
tion, to allay pain and prevent the general irritation from being rein-
duced. Atmospheric influence should also be attended to; in many
cases—more especially when this form of sore is of secondary accession
—this would seem to be the predisposing, if not the exciting cause of
the disease ; and whenever circumstances give rise to such suspicion,
the patient ought of course to be carefully excluded as much as possible
from the operation of such untoward agency. The diet should be good
yet non-stimulant; in the first instance, at all events, restriction to the
farinacea will be expedient.
As to the local management, surgeons are not yet quite agreed; one
party advocating the most lenient measures—poulticing, rest, and ex-
pectancy ; while another are in favour of severe and active remedies—
escharotics—at the outset, in order to cut short the disease, and—along
with the suitable constitutional treatment—to change the character of
the sore into the healing type. Among the latter I confess myself to
be enrolled; and simply because my experience of both gives, to my
perception, a decided superiority to the energetic over the expectant
system. One reason why some have lost faith in the active remedies
I believe to be, that these have not been efficiently applied. Great
humidity has been already stated to be a prominent characteristic of the
majority of such sores. An escharotic applied to the parts unprepared,
proves almost inert: for it is dissolved by the fluids, and passes off after
having but grazed the solids. The first, and a most essential, part of
the manipulation is to dry the surface and parts around thoroughly, by
tow or lint, gently yet firmly applied ; at the same time loose sloughs
are taken away, and the thickness of adherent dead parts diminished,
by scissors. Thus, and thus only, is the sore prepared to be duly af-
fected by the escharotics. Of these, two are most in favour; nitric
acid, undiluted; and a strongly acid solution of the nitrate of mercury.
The former seems the more adapted for general use; and is certainly
preferable for the first application, being equally effectual in forming an
immediate and sufficient eschar, and followed by a considerably less
continuance of pain. A flat piece of wrood, or a director wrapped
round at the extremity with lint, is soaked in the acid, and then pressed
firmly on every part of the affected surface, as well as on the yet living
margins; continuing the application until all has been converted into
eschar; and protecting the surrounding integument, by carefully wiping
up the fluid product. _ The part is then covered by a soft warm poul-
tice ; this application is continued until the eschar begins to separate,
when it may be conveniently superseded by the warm water-dressing;
and not unfrequently this maybe slightly medicated by solutions of the
chlorides of Hme or soda, as correctives of fcetor, and detergents. So
soon as detachment jjas begun, a careful and anxious examination ifl
ON ULCERS.
19
made of the subjacent part, more especially at the very margin, in order
to ascertain whether the sloughing action has been arrested or not. If
it has, a healthy surface will be found, either simply ulcerating, or al-
ready shoAving signs of repair by granulation; and the simple water-
dressing is continued. If it has not, the ash-coloured slough will be
found again forming, or else rapid destruction is seen advancing in the
phagedaenic form; and the escharotic must be at once and freely re-
peated, directing its operation chiefly to the margins, as there the chief
tendency to extension of the evil Avould seem to reside. And if need
be, such repetition is continued, until the destructive action has been
finally and fully controlled. In the reapplications the nitric acid may
be well superseded by the nitrate of mercury; not as a more efficient
escharotic, but as a more successful alterative of the nature of the sore ;
it is liable to but one objection, namely, that a burning pain is not un-
likely to continue for several hours: this is in part obviated, however,
by the simultaneous exhibition of the internal sedative and anodyne, as
formerly advised. In no instance should the preparatory drying of the
part be omitted ; it is as necessary in the last application, as in the first.
Be it likewise remembered, that this class of sores is communicable by
contagion; that consequently much personal cleanliness is demanded
towards each patient; and that in hospital practice, all community of
dressings, and every other circumstance likely to effect conveyance of
the contagious matter, must be scrupulously avoided.
On the arrest, even partial, of the sloughing and phagedenic pro-
cesses, by the local treatment, the constitutional symptoms undergo a
marked improvement. For the effect of the escharotic is not merely
to convert both deacl and dying parts at once into an eschar ; but also,
by changing a soft, pulpy, semi-fluid mass, into one wdiich is compa-
ratively hard and dry—at the same time establishing a sthenic inflam-
matory, and ulcerative process, for the dead part's separation, in the
comparatively sound texture immediately beyond—a process unfavour-
able to absorption—the maintenance and increase of constitutional con-
tamination from the absorption of deleterious matter, both fluid and
gaseous, are obviously diminished. When the sloughing has ceased,
when the sloughs are almost separated, and when granulation is fairly
established—the characteristic humidity, fcetor, and pain, all gone—
the febrile disorder will be invariably found to have greatly subsided;
then tonics and generous diet have become expedient, to allay the
hectic tendency, and maintain constitutional poAver sufficient for local
repair.
Such being the treatment most suitable to this class of sores, it is
very obvious hoAV important it must be in all cases, to diagnose accu-
rately between what is really of this nature, and the mere simulation
by accidental sloughing in the simply inflamed ulcer; the one requiring
a painful escharotic,' with the treatment suitable to constitutional irrita-
tion ; the other, merely continuance of bland poulticing, with moderate
antiphlogistics.
It need scarcely be added that in no instance of the genuine form is
blood-letting advisable ; as already seen-, local loss of blood sometimes
occurs in the progress of the disease; occasionally for good, but per-
200
PRINCIPLES OF SURGERY.
haps more frequently for evil; in all circumstances it is certainly an
event of much hazard, Avith a leaning to the side of evil sufficient to
forbid its rash institution by the practitioner.
Mercury, too, is not to be thought of. As a general rule, is slough-
ing and phagedaenic sores, more especially when of venereal origin,
mercurial medicines are always to be Avithheld; as certain to prove
more or less pernicious—in many cases disastrously so. The disease
is aggravated. Indeed, supervention of the constitutional disorder
attendant on mercurial exhibition, is often the obvious cause of com-
paratively healthy sores degenerating into the sloughing or phagedaenic
forms.
Escharotics, it will be observed, have been spoken of as applicable
only to the scrofulous—potass; and the sloughing and phagedenic—
nitric acid and nitrate of mercury. But in some cases of both the
weak and the irritable sores, especially when attendant on marked con-
stitutional disorder, should the characters obstinately remain perverse,
notwithstanding due perseverance in the ordinary mode of treatment,
escharotic destruction of the irretrievably diseased parts may be effected,
with a good hope of finding, on separation of the slough, a sound
foundation for repair.
Peculiarities of Ulcers.
Many sores on the lower extremities are accompanied, or rather
caused by—at least in part—a varicose condition of the veins ; and by
some the " Varicose Ulcer1'' is entered into the general classification.
But in truth this term does not express any individual kind, but rather
comprehends every variety of sore ; for all, or almost all, may be at-
tended by, and partly result from, a varicose condition of the veins.
The irritable is very common under such circumstances ; so is the in-
flamed. The indolent and weak, especially the former, are said by some
to be the types of the most frequent examples of the varicose ulcer; but
according to my experience, neither are more common than the irritable.
Occasionally the scrofulous is found complicated with varix; we may
have even the sloughing and phagedaenic—and in that case profuse
venous hemorrhage is to be expected and guarded against. Perhaps
the least frequently accompanying is the healthy sore—as can be easily
understood, when it is remembered that varix and passive congestion
are all but synonymous, and that this state is very unfavourable to all
sthenic and salutary vascular action.
The treatment will necessarily vary according to the character of the
sore, independent of the varicose complication—poulticing and rest to
the inflamed, stimulants to the weak, nitrate of silver to the irritable,
straps to the indolent, &c. But, besides, it is of course essential to
deal with the obvious predisposing cause, the varix. If this be great
and of long standing, and have induced oft-repeated ulceration of a
troublesome and grievous nature, the radical cure of the varix ought
certainly to be attempted, in the Avay which will be explained when
speaking of the treatment of this-disease. But as this requires confine-
ment for some time, and is not altogether void of danger, in the slighter
ON ULCERS.
201
and more ordinary cases the prudent surgeon contents himself with the
palliative management; that is, by rest and recumbency during the
ulcerating and healing processes ; and by uniform support, from ban-
daging or a laced stocking, both then and subsequently. Even during
the acutely ulcerating, and even in the phagedaenic form of sore, a cer-
tain degree of support is advisable—slight, uniform, and never amount-
ing to direct pressure on the raAV surface—in order to obviate accidents
by the sudden occurrence of hemorrhage. At the same time much at-
tention is paid to the loAver bowels, keeping them clear of obstruction,
and thereby removing a cause, not more obvious than common, of
occurrence and continuance of varix in the lower limbs.
2. The lodgment of foreign matter may complicate the ulcer, effec-
tually preventing cicatrization. This may have come from Avithout,
and consist of Avood, stone, iron, cloth, &c.; by impaction originally
causing inflammation and abscess ; and then by delaying contraction of
the open suppuration, establishing the condition of ulcer. Or it may
have an internal origin ; consisting of necrosed bone, dead tendon, or
ordinary slough of fascia or cellular tissue ; the result of suppuration,
either then or previously. Of Avhatever nature, and Avhencesoever
come, the foreign body is ahvays amenable to but one treatment—■
early and complete removal. Some little excitement foUows the mani-
pulation necessary to effect that object, and is to be met by rest,
fomentation, poultice, and other usual antiphlogistics ; on subsidence,
the granulating process begins, and is conducted under the ordinary
treatment.
3. The condition of sinus may co-exist with that of ul er, preceding
or accompanying. If it fill not up and contract spontaneously; keeping
pace with the corresponding change in the sore, it is to be treated inde-
pendently. Pressure in the first instance is applied, direct, and regu-
lated according to the principles formerly inculcated. If this"fail then
the sinus—usually very superficial—is to be laid open, either by the
knife, or by the potassa fusa, as circumstances may render expedient.
If the term sinus be applied to the undermining of integument, and un-
soundness of cellular tissue, which invariably characterize the scrofulous
sore, then the use of the potass to these will be invariable, for the rea-
sons formerly given.
4. Sometimes sores are vicarious in their nature. In females, for
example, ulcers may form on the leg, or elsewhere, obviously connected
with the menstrual secretion ; becoming active, enlarging, and emitting
a profuse discharge—sometimes sanguinolent—while the menstrual flux
is, or should be, in progress; contracting, becoming dull, compara-
tively dry, and perhaps partially cicatrizing during the intervals. Such
sores, it is plain, can be attacked with safety only through the uterus.
The functions of that organ must in the first instance be duly restored:
then, and not till then, our attention is to be directed to the obtaining
of cicatrization.
5. The healing of certain sores 4s never to be attempted. For exam-
ple, when a sore has existed for many years, almost stationary, or only
varying with obvious changes in the system ; tending to inflame and
extend, during constitutional disorder, contracting again when this sub-
202
PRINCIPLES OF SURGERY.
sides, yet never approaching to complete cicatrization Avithout ill health
ensuing—and this again relieved by re-establishment of tho sore.
When the gouty diathesis is strongly marked, and its alterations are
plainly connected Avith the ulcer's varying state. When the patient is
advanced in years, has been in hot climates, and may AYithout injustice
be termed a bonvivant. Under these circumstances, or such as these,
we do not think of drying up the sore—which may be truly looked
upon, somewhat as a safety valve to the system—but content ourselves
with the application of some simple and soothing dressing, such as the'
wet lint and oiled silk; leaving Avhat may be termed the ebbing and
floAving of the ulcerative process entirely in the hands of Nature; our
dressing tending simply towards comfort and protection.
6. Some sores may be healed with safety, but only when an issue for
some time supplies their place, as a drain in the general economy. A
sore, secreting constantly a considerable quantity of pus, may have ex-
isted for years in the limb of an elderly patient. No prudent surgeon
would ever propose to dry up that suddenly by rapid cicatrization—if
he had it in his power so to do—Avithout leaving some substitute in its
room, at least for a time. For the sudden cessation of purulent dis-
charge, to which the system had been long habituated, would be cer-
tain to occasion a plethora ; this in its turn inducing determinations of
blood to certain parts ; and thus serious danger to the important internal
organs would accrue, by hemorrhage, sanguineous infiltration, or esta-
blishment of the inflammatory process. Apoplectic seizure is especially
probable under such circumstances. Yet doubtless the continuance of
such a sore is not only a considerable inconvenience, but likewise has
a debilitating effect on the general system, and consequently tends to
the induction of diseases to whose accession constitutional debility is
favourable ; its closure is therefore desirable. And should none of the
unpropitious circumstances exist, as stated in the preceding paragraph,
such closure may be safely enough conducted in the ordinary way;
taking care, however to establish an issue in some convenient and ad-
jacent spot, as soon as the discharge begins to materially lessen. This
artificial drain is kept in full operation for some time—a fortnight or
three weeks—and then, by gradually diminishing the bulk of the foreign
body by whose presence healing is prevented and discharge maintained,
the system is so gradually subjected to the diminution of the waste, that
its ultimate cessation is scarcely appreciated.
7. Ulceration is a very frequent attendant on malignant disease ; and
is then termed malignant or cancerous. This will be considered in an
after part of the volume.
ON MORTIFICATION. 203
CHAPTER VI.
MORTIFICATION.
Having already considered the nature and progress of mortification
in general; and more especially that very common form which is the
highest result of the inflammatory process ; Ave now proceed to notice
other causes of this serious change, and the treatment to which the dis-
order is amenable.
As to terms ;—the ordinary division of the subject is into acute and
chronic ; the acute comprehending the humid, inflammatory, and trau-
matic ; the chronic—the dry and idiopathic. Generally speaking, the
acute is humid, and the chronic dry: the fluids being retained in the
one case, and parted with gradually in the other; but this is not in-
variably the case.
The cause of mortification may be broadly stated to be, whatever is
hostile to vital power. But it will be convenient to examine this state-
ment more in detail; considering separately those causes of local death
which most frequently come under the notice of the surgeon.
1. Inflammation, Ave have already seen to be a very frequent cause
of mortification ; by intensity of action; by want of vital power—in
part, system, or both—to control action, otherwise not excessive ; or by
a conjunction of both circumstances. The gangrene may be said to be
invariably humid; for not only is there no dissipation of the normal
fluids of the part, but an absolute and decided increase of them by the
inflammatory effusion.
2. Mechanical injury may occasion local death either directly or in-
directly. The violence may have been" 90 great as at once to crush
and disorganize the part, instantly depriving it of life. Or, less intense,
it may have but loAvered vitality by partial disruption of texture, at the
Bame time acting as a palpable exciting cause of the inflammatory pro-
cess therein, and so rendering the occurrence of gangrene by inflamma-
tion all but inevitable. Both forms are sufficiently common ; and both,
but especially the latter, are prone to spread rapidly, greatly endanger-
ing life by poisoning of the system. The mortification is acute and
humid.
3. Pressure, gently applied, occasions absorption; a higher grade
causes vascular action in a perverted form ; a higher gives the true in-
flammatory products, suppuration and ulceration ; and_ a higher still
occasions death of the part. The last result may be either direct or
indirect; that is, with or without the intervention of vascular^action.
Pressure being considerable and constant, with a Ioav power in both
part and system, death of the former may be immediate ; as may often
be observed in the formation of bed-sores in the helpless and bed-rid-
204
PRINCIPLES OF SURGERY.
den. Or, as was stated of mechanical injury in general, the pressure
may excite the inflammatory process and lessen vital poAver simulta-
neously, so rendering the part an easy prey to the former.
4. Heat, in like manner, may be so intense as at once to char the
part, rendering it instantly dense, black, and brittle, as in the severest
class of burns. Or it may only diminish power and excite inflamma-
tion, as in the more common examples of this form of injury. Acids,
and other chemical destructives, act in a similar way.
5. Obstruction to Venous Return.—The gangrenous effect of this is
indirect. Passive congestion is induced ; and so long as the obstacle
to venous return continues, the venous accumulation, with consequent
effusion into the surrounding parenchyma, is inevitably increased.
This anormal state, necessarily weakening vital poAver, is also likely to
excite the inflammatory process, as formerly shoAvn; and but a slight
amount of action will suffice to overpower in such circumstances.
Thus, gangrene of the Avhole forearm has resulted from injudicious
bandaging, or other deligation, of the arm, no support having been
afforded to the parts beneath. Retain the tight ligature used for vene-
section, and gangrene will be certain sooner or later to ensue—through
the intervention of inflammation. Or the obstruction may be by spon-
taneous change in the principal venous trunk, it becoming solidified by
coagulation of its contents, or by fibrinous effusion ; or from compres-
sion by tumours of various kinds; or by organic change in internal or-
gans—as the liver and heart.
6. Deprivation of Nervous Agency, also acts indirectly. Bed-sores
by sloughing are well knoAvn to be most prone to form, in cases of in-
jury of the spine; the pressed parts being paralytic. Power is dimi-
nished, a tendency to action is induced, and the application of a com-
paratively slight stimulus suffices to ensure the gangrene. Sometimes
no direct employment of exciting cause is necessary ; the cornea has
sloughed after division of the fifth nerve ; the same act at once arousing
action and cutting off the nervous agency.
7. Interruption to Arterial Supply.—This may be complete, causinga
direct cessation of life. A tourniquet screAved so tightly on a limb as
to arrest entirely its circulation, and so retained, inevitably entails death
of the whole limb beneath the encircled point; for, invariably, on com-
plete arrest of circulation, vital action ceases, and chemical change
speedily begins. Besides, ordinarily, arterial influx can only be effec-
tually arrested by such means as will at the same time cut off all nervous
influence ; rendering retention of vitality, if possible, still more hopeless.
Or, the instrument may be applied with tightness sufficient to diminish,
yet not to stop arterial influx; and then the result Avill be indirect, as
in the case of obstruction to venous return only ; action being excited,
Avhile poAver is depressed. Or, after deligation of the principal artery
of a limb, weakening vital power—inasmuch as collateral circulation
can never be at first quite equal to the normal arterial supply—heat,
friction, or other stimuli are applied ; and gangrene occurs. The first
is comparatively a painless process, being immediate ; pain ensues only
on the accession of inflammation in the adjoining living parts, whereby
the fine of separation is formed. The second is painful, because tedious,
ON MORTIFICATION.
205
and inflammatory throughout. And this it is important to remember.
When we wish to get rid of a tumour, for example, or other noxious
structure, not amenable to excision, we employ deligation. If we wish
further, that the destructive process be both speedy and easy to the
patient—as doubtless in the vast majority of cases will be our object—
we do not hesitate to put him to immediate pain, by tying the ligature
with as tight a strain as it will bear, so as thoroughly to cut off its ar-
terial supply, and altogether arrest its circulation. Whereas if unwisely,
we treat him now with a gentle hand, much unnecessary pain remains
for the future, the part being but partially strangulated, capable of as-
suming the inflammatory process, and the undergoing of that process
being essential to the cure.
The most obvious illustration of this cause of gangrene, is by sup-
posing deligation, from Avithout. But equally efficient obstruction to
arterial supply may come from Avithin ; by rupture of the principal artery
or arteries ; by consolidation of their canals from fibrinous deposit of a
plastic kind ; or by earthy degeneration of the vessels^ as will after-
wards be shown.
Perhaps the tendency to gangrene in inflamed unyielding textures
may be caused, at least in part, by the tension, which, invariably en-
sues, so compressing the part as either to arrest or seriously impede the
already Aveakened circulation.
In surgical operations it is very useful to bear in mind, how sudden .
and effectual obstruction of both arterial influx and venous return is
likely to prove fatal to the part. For instance, in performing deliga-
tion of the principal artery of a limb on account of aneurism, we will
be especially careful to avoid injury to the concomitant vein ; for if that
be obstructed as Avell as the artery, gangrene of the limb—even Avith-
out the intervention of undue stimulus—is extremely probable. If Ave
can imagine the principal nerve to be at the same time seriously in-
jured, gangrene is all but inevitable, under the three-fold evil influ-
ence of arterial and venous obstruction with deprivation of nervous
agency.
8. Cold.—The effect may be direct or indirect; more frequently it
is the latter. But direct it may be, thus. The immediate effect of
cold, intense, and continuously applied to the part, is greatly to de-
press both its circulation and its nervous energy ; and this depression,
by continuance of the cause, may be carried so far as altogether to
annihilate vital poAver. The part in truth is frozen to death ; becoming
cold, insensible, shrivelled, and discoloured ; by and bye undergoing
obvious chemical change, and becoming detached by the ordinary pro-
cess of separation. This is likely to occur only in very cold climates;
even then, only when the individual is exposed to hardship and priva-
tion ; and the parts most liable to be so affected, are those most remote
from the centre of circulation, and consequently by nature less fully
endowed by vital poAver; and also those most habitually exposed to
atmospheric inclemency—as the toes and feet, and the tips of the nose
and ears.
Much more frequently the action is indirect. Cold is applied, and
the lowering result follows as usual, to a greater or less extent. The
18
206
PRINCIPLES OF SURGERY.
cold is suddenly removed, or very likely warmth with the additional
stimulus of friction is applied, and the inevitable consequence is imma-
ture and excessive reaction, the blood rushing back to the part it had
but lately left, Avith far greater impetuosity than it had before, distend-
ing every vessel to the utmost, and hurrying on the inflammatory pro-
cess—and this in a part not yet recovered from the depression of vital
poAver which the first effect of the cold had occasioned. The action is
sudden and intense, poAver of resistance and control is low, gangrene
is inevitable. It is not the patient Avho is simply exposed to diminished
temperature, that suffers from chilblain—chronic inflammatory process
in a debilitated part; or from frost-bite—the inflammation, more acute,
having reached sloughing; but it is the patient Avho after exposure to
cold, warms himself at the fire, or simply enters a heated room; or
who, not contented with abstracting cold, and applying heat, adds fric-
tion to the affected part. Illustrations of this are of constant occur-
rence ; but there is one, on a large scale, Avhich though trite, is altoge-
ther so apposite and striking that I think it expedient, by Avay of
corroboration, briefly to notice it here. In continuing his narrative
after the battle of Eylau, Baron Larrey says—" During three or four
exceedingly cold days that preceded the battle, the mercury having
fallen so low as fifteen degrees beloAV zero of Reaumur's, and until the
second day after the battle, not a soldier complained of any symptom
depending on the freezing of the parts; notwithstanding they had passed
three days, and a great portion of the nights of the 5th, 6th, 7th, 8th,
and 9th of February, in most severe frost. The Imperial guard in par-
ticular had remained upon Avatch in the snow, hardly moving at all for
more than twenty-four hours, yet no soldier presented himself at the
Ambulance. In the night of the 9th and 10th, the temperature sud-
denly rose, the mercury ascending to three, four, and five degrees above
zero. From this moment, many soldiers of the guard and line applied
for assistance, complaining of acute pain in the feet, and of numbness,
heaviness, and prickings in the extremities. The parts Avere severely
swollen, and of an obscure red colour. In some cases, a slight red-
ness Avas perceptible about the roots of the toes, and on the back of the
foot. In others the toes were destitute of motion, sensibility, and
warmth ; being already black, and as it were dried. All the patients
assured me that they had not experienced any painful sensation during
the severe cold, to Avhich they had been exposed on the night watches.
It Avas only when the temperature had (suddenly) risen eighteen or
twenty degrees, that they felt the first effects of the cold as inducing
mortification." And it is added, that those who had Avarmed them-
selves at fires suffered most.*
But cold may in a similar way cause death, not of a part, but of the
whole body. General vital power is depressed; sudden reaction ensues,
by the imprudent-use of stimulus; and under this action the enfeebled
system may succumb. To illustrate this, let us again quote from Lar-
rey. " Woe to the man benumbed with cold......if he entered too sud-
denly into a Avarm room, or came too near to the fire of a bivouac......
* Larrey's Memoirs, torn. iii. p. 60.
ON MORTIFICATION.
207
gangrene made its appearance at the very instant, and spread with such
rapidity that its advances were perceptible by the eye ; or the individual
was suddenly suffocated with a kind of turgescence, Avhich appeared
to affect the brain and lungs; he perished as in asphyxia. Thus died
the chief apothecary of the Guards......He had scarcely been a few
hours in this (Avarm) atmosphere, so new to him, when his limbs, in
which he had lost all feeling, became considerably swelled, and he ex-
pired soon afterwards, incapable of uttering a single word."*
9. Animal and other Poisons, applied to a part, by inoculation or
otherwise, are usually said to be poAverful excitants of gangrenous in-
flammation. That is they lower vital power in both part and system,
at the same time exciting the inflammatory process in the vicinity of
the wound. Bites of serpents act in this way; as also inoculation of
putrid virus from cattle, or others of the loAver animals, occasioning the
" malignant pustule ;" and, much in the same way, there is no more
certain cause of rapid and extensive gangrene, Avith most serious results
to the system, than by the infiltration of urine into cellular tissue.
Hitherto we have considered chiefly such causes as are local and
external; we now come to those which are constitutional and internal.
10. General debility, from any cause—hemorrhage, starvation, age,
persistent disease, or long continuance of any generally depressing
agent—predisposes both to the accession of perverted vascular action,
and to its untoAvard advance; there being but little power, either in
part or system, for resistance or control. Or vital power may be so
far diminished, especially in those parts naturally the Aveakest, being
most removed from the centre of circulation, as to cause death in a
more direct wa}/, Avithout the intervention of inflammatory action;
simply by mal-nutrition, and gradual failure of vitality in consequence.
This latter mode is not unfrequently exemplified by simple gangrene of
the toes after exhausting fever.
A peculiar disorder of the system, certainly not of the purely sthenic
type, attends on the internal use of mercury, carried to sustained
ptyalism. This seems very favourable to the assumption of the inflam-
matory process, and to the invasion of sloughing, as well as of fierce
ulceration, during its progress; a fact abundantly exemplified by the
frequent occurrence of sloughing and phagedaena, in an aggravated
form, in venereal patients recklessly salivated.
11. Improper food, habitually taken, leads to disorder of the system
of a feeble type, and thus will at least predispose to gangrene. But
one poisonous article of diet, in particular, causes a constitutional dis-
order of a very aggravated character, an almost invariable result of
which is chronic and dry mortification of the extremities. The article
alluded to is an unsound kind of rye, not uncommon in the north of
Europe. A black curved excrescence, not unlike the spur of a fowl,
grows on the spike, and sometimes is found in such quantities as to
form nearly one-fourth of the produce of the rye ; it is termed the ergot
of rye, or secale cornutum. Its habitual use as food induces lassitude,
weakness of the extremities, a feeling of intoxication, and periodic
._____________________________---------------------1---------
* Op. Cit. torn. iv. p. J34.
208
PRINCIPLES OF SURGERY.
convulsive movements. This state, called raphania, may continue for
days or months. And frequently, during its persistence, mortification
of the extremities occurs, beginning in the toes and gradually extend-
ing up the leg, attended Avith but little pain, and Avithout appreciable
precursory inflammation ; the part becoming at once cold, insensible,
and discoloured, and gradually dry, hard, and shrivelled. In some of
the recorded cases, the line of demarcation formed, separation was
completed, and recovery took place ; in the majority, however, the dis-
ease advanced unchecked in either its constitutional or local form, and
the issue was fatal. In this country, a somewhat similar malady has
been traced to the use of unsound Avheat.
12. Atmospheric influence acts favourably or otherwise on the sys-
tem, more especially of the invalid. When a deleterious impression
has resulted, no uncommon indication of this is the appearance of
sloughing in a previously healthy wound or sore. To such a cause for
example, the invasion of hospital gangrene is perhaps most frequently
attributable.
13. Arterial degeneration.—In advanced years, the whole arterial
system, but more especially the ramifications in the loAver extremities,
are liable to degenerate, by deposit of calcareous matter between the
coats, to a greater or less extent; sometimes converting them into com-
pletely rigid, and as if altogether ossified tubes. This of itself may
exist so generally, and in so advanced a form, as ultimately to render
effectual circulation through such altered conduits impracticable; and
circulation gradually ceasing, so does life ; death of the part ensues, a
gradual and painless process. Or, ere,the change has advanced so far
as to cause complete arrest of circulation, but quite far enough sadly to
enfeeble vital power, a low perverted action may be kindled by some
of the many exciting causes to which the part is liable ; and low though
such action be, it is usually sufficient to cause more or less extensive
gangrene, for it invades a part whose power of resistance and control
has been much impaired.
Again ; it has been supposed by some that perverted action is very
liable to occur in the vessels themselves Avhen so changed ;and as an
invariable result of arteritis is knoAvn to be consolidation of the arterial
contents, with consequent occlusion of the canal, and arrest of circula-
tion—this occurring generally in a limb Avould be certain to induce its
death. By Dupuytren it Avas imagined that the greater number of
cases Avere thus to be accounted for. But, without denying the possi-
bility of the occurrence, or that it does sometimes so cause mortifica-
tion in the aged, it seems more reasonable to believe that the painful
and inflammatory form of this disease is attributable to that action having
iuAraded not the arterial tissue alone, but the whole part.
Thus Ave find the old man peculiarly exposed to mortification, parti-
cularly in the parts naturally most weak—the feet and toes. To such
mortification, usually gradual, chronic, and dry, the term Gangrena
senilis is commonly applied. This disease, however, is not to be con-
sidered as invariably occurring in one way, and consequently in all
cases amen|able to one and the same mode of treatment, otherwise much
practical evil must result; indeed, there is good reason to believe, that
ON MORTIFICATION.
209
from this very circumstance, not a few lives have been hurriedly dis-
posed of, which otherwise might have been long protracted.
The senile gangrene varies in its nature. 1. It is not necessarily j
attended by arterial degeneration. And when not so accompanied, but '
induced by simple general debility, incidental to advanced years, and
perhaps aggravated by casualties to which every age is liable—it may
occur with or without the intervention of inflammation. Circulation
and vital power may gradually cease ; or the latter is overborne by
accession of perverted vascular action. 2. Likewise, when calcareous
degeneration does exist, there is a similar alternative of events ; the
death may be inflammatory or not; actually painful, or comparatively
painless.
In practice, perhaps the most important division of this form of mor-
tification is into that Avhich is preceded and accompanied Avith perverted
vascular action, and that Avhich is not; for to the variety of cause, ought
the mode of treatment to be accommodated.
The accompanying inflammation is always of rather a low type, the
part of enfeebled power being not only easily evercome by such, but
being really incapable of assuming an action of high intensity ; in con-
sequence the term of inflammatio debilis is often applied.
Or the inflammatory and non-inflammatory forms may be blended.
The latter may seize on one or more toes, converting them simply and
quietly into black and shrivelled eschars ; and, after a time, the morti-
fication ceases to extend upwards. As usual, an effort is then made
by Nature to throw off the dead and noxious parts; and this we know
can be effected only in one way, by inflammation and ulceration. The
action is accordingly assumed at the living margin ; and heat, redness,
swelling, pain, appear there. But the part has no sufficient poAver of
control; the desired result of ulceration and suppuration is quickly
overpassed, and mortification ensues. The inflammatory has become
engrafted on the simple form, and proceeds rapidly, Avith much pain
and constitutional disturbance. It would seem as if the effort, by vas-
cular action, toAvards arrest and separation were being constantly made,
and never with success; on the contrary accelerating the destructive
progress.
Thus then we may have senile gangrene, throughout unattended
with pain, redness, swelling, or other signs of the inflammatory pro-
cess—excepting, ultimately, the line of separation. Or from the be-
ginning these are present, and continue, until either arrest of the disease
or death of the patient ensue. Or the pain, heat, and redness, though
at first absent, may supervene; and then continue of an aggravated
character.
The disease is most liable to occur in males, of the higher ranks,
and who have indulged freely and habitually in the pleasures of the
table—all the more likely if organic disease of the heart or aortic valves
be present. And the most frequent form, is that which is attended by
the inflammatio debilis. The original description by Mr. Pott merits
quotation. He calls it " that particular kind of mortification, which,
beginning at the extremity of one or more of the small toes, does, in
18*
210
PRINCIPLES OF SURGERY.
more or less time, pass on to the foot and ankle, and sometimes, to a
part of the leg ; and, in spite of all the aid of physic and surgery, most
commonly destroys the patient." Usually " the patients feel great un-
easiness through the Avhole foot and joint of the ankle, particularly in
the night, even before these parts shoAV any mark of distemper, or be-
fore there is any other than a small discoloured spot on the end of one
of the little toes. It generally makes its first appearance on the inside,
or at the extremity of one of the smaller toes, by a small, black, or
bluish spot: from this spot the cuticle is ahvays found to be detached,
and the skin under it to be of a dark red colour. Its progress in diffe-
rent subjects, and under different circumstances, is different; in some
it is sIoav and long in passing from toe to toe, and from thence to the
foot and ankle ; in others its progress is rapid, and horribly painful. It
generally begins on the inside of each small toe, before it is visible
either on its under or upper part; and when it makes its attack on the
foot, the upper part of it first shows its distempered state, by tumefac-
tion, change of colour, and sometimes by vesication ; but Avherever it
is, one of the first marks of it is a separation or detachment of the cuti-
cle."—The constitutional symptoms are such as characterize gangrene
in general; that is, constitutional irritation, tending towards typhoid
collapse ; but chronic in its nature, like the local action ; and pain, rest-
lessness, and hiccup—especially the two former—are particularly pro-
minent. In the non-inflammatory form, the constitutional disorder is
often very slight, at least during the commencement of the gangrene.
The Progress of mortification is sometimes slow, making but little
advance in days and even Aveeks—as in the senile and other chronic
forms. Sometimes it is fearfully rapid, as in the acute and traumatic,
spreading within a few hours over a Avhole limb.
When arrest has occurred, Nature begins her process of separation,
as formerly described. A sthenic form of inflammation is established
in the living margin ; suppuration and ulceration supervene ; and this
destructive action is in its turn followed by granulation, and effort
towards repair. At the same time the symptoms of constitutional irri-
tation gradually subside, and a sthenic and normal state of system is
gradually restored.
The Prognosis varies according to the extent of the mortification, the
nature of the part in Avhich it has occurred, and the condition of the
system during and before its accession. The larger the gangrened
part, the more important it is as a part of the general economy, and
the lower the constitutional powers, the greater the danger to life; and
vice versa.
Treatment of fortification.
The treatment of mortification in general resolves itself into five
principal indications. Remove or mitigate the cause; wait for the
ON MORTIFICATION. 211
line of demarcation ; assist Nature in her efforts towards detachment;
promote and regulate the healing process ; and maintain due power of
system throughout invasion, arrest, and cure.
But in the first place let diagnosis be accurate ; be sure that it is a
case of gangrene. In mere bruise there is a discolouration of a livid hue,
and dark-coloured serous vesicles form somewhat resembling phlyctenee;
but the points of difference, formerly noticed, are sufficiently plain.
And it is well that such is the case, inasmuch as error of diagnosis
would infallibly lead to serious error of practice. On undoing a frac-
tured limb, for example, after the first application of retentive apparatus,
it is not uncommon to find it SAVoln, darkly discoloured, and studded,
by dark vesications. If this be gangrene, amputation, at some distance
above the parts so affected cannot be too soon performed. If it be but
the effects of bruise, fomentation, mild antiphlogistics, and gentle re-
application of the retentive means, are all that the circumstances
demand.
In the inflammatory form, removal of the cause is to be attempted by
antiphlogistics. And, prevention being better than cure, it will of
course be advisable to have recourse to these early and efficiently, to
arrest the inflammation's progress timeously, and save the vitality of
the part. But let not the chance of immunity from gangrene be pur-
chased at too high a cost. Copious general blood-letting, with other
spoliative and depressing remedies, may make much impression on the
inflammatory action, and so at least limit the occurrence of gangrene
at the time ; but the process of separation of the dead parts, folloAved
by attempts at repair, has to come, Avith its exhausting discharge ; the
powers of the system are certain to be severely tried ; and if they have
been at the outset imprudently exhausted, they cannot fail to sink when
they are most required. Besides, the bleeding may not even secure
the temporary benefit; on the contrary, general and local poAver may
be so Aveakened thereby, as to render them an easy prey to the action
even in a subdued form. It is often that antiphlogistics are thus used
Avith a blind and rash improvidence; the cure is protracted and em-
harassed ; the system is enfeebled, and perhaps for ever broken; or
even the issue may be fatal. Cases of threatened gangrene after severe
bruise, laceration, fracture, &c. afford abundant illustration of this prac-
tical point. The ulterior result must always be regarded, along Avith
the present; and both provided for. We are to prevent or limit gan-
grene, if Ave can ; yet Avielding antiphlogistics so as to make sure of
leaving poAver enough of system, for defence from hectic and ex-
haustion during the suppurative stage.
Also let it be borne in mind, that it is only before and at the very
commencement of the gangrene, that antiphlogistics can ever be actively
employed. When mortification has been fairly established, the symp-
toms change, and require a corresponding alteration of treatment; in-
flammatory fever, sthenic, is superseded by the asthenic constitutional
irritation. And further ; Avhen gangrene is both certain to occur, and
to prove extensive, the class of symptoms corresponding to that result
are often fore-shadowed in the characters of the preceding action,
both locally and generally J modifying these in so marked a manner, as
212
PRINCIPLES OF SURGERY.
at once to enlighten the experienced practitioner as to the impending
issue. Such a state not unfrequently connected with a previously
debilitated poAver of system, is often, and not inappropriately, termed
the gangrenous inflammation ; and in this, antiphlogistics, at however
early a period employed, must invariably be used Avith the greatest
caution and forbearance. On the other hand, if the inflammation be
intense, limited, seated in an important part, with both local and general
symptoms plainly sthenic in character, and occurring in a robust un-
broken frame—we bleed copiously and fearlessly, employing also the
other suitable antiphlogistics with energy. For, in these circumstances,
such are the only true preventives of gangrene.
But constitutional remedies, foolishly held as specifics, and termed
antiseptics, were at one time much in vogue, and may not yet have
fallen altogether into desuetude. Of these the most prominent was
bark, given in full doses. The exhibition of this at an early period,
will plainly aggravate the disorder—offend the stomach, increase the
inflammatory fever, influence the local action unfavourably, and render
the gangrene both more speedy and more extensive than it otherwise
might have been. It can only be of use, as other tonics, after the
period of excitement has gone by ; limiting or preventing hectic, and
assisting the system to bear up under the exhausting influence of sup-
puration.
Previous to gangrene by inflammation, then, antiphlogistics are expe-
dient ; early, active, yet cautious ; invariably controlled by regard to
the impending future ; their object is to prevent local death if possible,
and yet not seriously impair general poAver. When gangrene has
occurred, they may be continued, in sthenic cases, but now with still
more subdued caution; to limit the mortification as much as possible,
but still without injury to the system. When, however, the constitu*
tional symptoms of gangrene are fully developed, of their usual type,
antiphlogistics are wholly unsuitable; the disorder has passed from
inflammatory fever into a grave form of constitutional irritation tending
to collapse ; and calmatives, support, tonics, stimuli, will probably be
required. Opium, in full doses, and pretty frequently repeated, is an
admirable remedy at this stage ; calming the general system, blunting
the sensation of pain and illness, and seeming to impart a power of
tolerance to the frame under the depressing agency of the gangrene.
At the same time more or less stimulus is usually required; and the
preferable forms are the alcoholic and ammonia ; administered with the
cautions formerly explained. Hiccup, it will be remembered, was
spoken of as particularly troublesome in many cases ; if it do not yield
to the general treatment, musk, camphor, ammonia, may be employed
as special correctives. When the gangrene has ceased, and separation
been commenced, usually the general symptoms again change towards the
sthenic form; and in consequence, a guarded and somewhat antiphlo-
gistic regimen will probably be expedient, lest the action necessary for
detachment should prove excessive, and reinduce sloughing; but, on
the contrary, should both general and local appearances betoken debility,
cautious support by nourishing food, and the more simple tonics, must
be maintamed. When detachment has been completed, we have then
ON MORTIFICATION.
213
to do with a simple sore—inflamed, ulcerating, granulating ; Aveak,
irritable, or healthy, as the case may be—and the ordinary treatment is
to be conducted accordingly.
If a palpable exciting cause appear—as deligation, obstructing venous
or arterial circulation, or both—that of course must be instantly re-
moved. Infiltration of poisonous or acrid fluid Avill be got rid of, or
limited in its effects, by free incision. Noxious atmospheric influence
must be either changed, or neutralized as far as possible. If sloughing
be from compression, the pressure must be removed or modified ; if from
bad food, diet must be amended; if from mere general debility, that
must be obviated by a suitable support.
Mortification by Pressure very frequently engages the attention of the
practitioner ; commonly as the result of long confinement to the recum-
bent posture ; sometimes by inaccurate or injudicious adjustment of
retentive apparatus in the treatment of fracture. When sloughing by
such causes has been induced, it proves a source of much inconvenience
to both patient and surgeon, as can be readily understood. It is to be
avoided by care in subdividing the pressure among many points, pre-
venting its concentration and maintenance on one or two alone. In
fracture of the leg, for example, the retentive means will be so arranged
as to compress not solely the malleoli or the heel, but to be equally
borne by the Avhole surface of the bandaged limb ; and such precautions
are especially desirable in the case of the aged and weak. When bed-
Bores are threatened, the points naturally most compressed—over the
sacrum, trochanters, heels, scapulge, elboAvs—must be relieved as much
as possible, by frequent variation of posture, by the adjustment of pads
or pillows on the adjacent parts, and if possible by the use of that
admirable contrivance for such purposes, the hydrostatic bed, by Avhich
the labour of support is equally distributed on every part of the surface.
The reddened and painful parts—for it is usually by inflammation the
part perishes, poAver being seldom so very small or pressure so great as
to occasion immediate and direct death—are to be pencilled over by
nitrate of silver, either in substance or in solution, so as merely to
blacken the integument, carefully avoiding the vesicating effect; our
object being simply to resolve the inflammatory process. At the same
time, of course, our utmost efforts will be directed towards the general
recovery of the patient, in order that recumbency may be disused.
When breach of surface has ensued, it early assumes the weak charac-
ters, requiring stimulating applications accordingly.
When mechanical or chemical injury is the cause, Ave have seldom the
poAver of altogether preventing mortification ; limitation is our object.
So soon as the first shock has passed over, our treatment is antiphlo-
gistic : in order that death may be confined to those parts which suffer
directly from the injury ; saving those Avhich have their vital poAver less
diminished, and Avhich might contrive to live if let alone, but which
would be unable to combat brisk inflammation successfully. A certain
amount of inflammation must ensue ; but we are anxious to limit that
to Avhat is merely necessary to effect detachment of the original slough.
During the progress of detachment, the antiphlogistic regimen will be
probably expedient; thereafter, by improved diet, and other tonic
214
PRINCIPLES OF SURGERY.
means if necessary, the general poAver is to be maintained, sufficient to
ward off hectic and duly carry forward the operation of repair.
In the case of mortification from Cold, it is our duty to prevent the
occurrence if possible ; and as, in this climate, it is seldom that the
destructive result is by the direct effect, but by the secondary or reactive,
such prevention is not unfrequently within our poAver. Plainly, it is te
be effected by moderating reaction ; abstracting cold, and yet not apply.
ing sudden heat or other stimuli. The common practice is very suc-
cessful, and though perhaps not actually based on scientific principles,
can be most satisfactorily explained by them. A part undergoing the
freezing process—threatening to die by the direct effect of intense cold
—becoming pale, shrunk, and but little sensible, is rubbed with snow,
while the patient and part are yet in the open air, or at least not exposed
to sudden elevation of temperature. The rubbing arrests the sedative
effect, and induces reaction ; but rubbing Avith cold ensures the reaction
being gradual, slow, and safe ; circulation and nervous influence are
restored; and this returning vital power, finding no undue action to
oppose or control, reigns paramount.
When gangrene has set in, by reaction proving excessive, our object
is to moderate this, and at the same time sustain constitutional poAver;
poultice, water-dressing, pencilling by nitrate of silver, or other soothing
applications locally; careful regulation of diet, and administration of
suitable remedies internally—at first moderately antiphlogistic, then
opposed to constitutional irritation. On separation of the sloughs, the
customary treatment is adopted.
In the chronic gangrene of old people, the Gangrena senilis, we may
have tAvo distinct forms as already shown ; death, direct, from mere
want of poAver ; or death indirect, weakened power being overcome by
inflammatory action. In the former case, cautious general support is
expedient, enough to maintain and increase general poAver ; yet cautious
to avoid the induction of an inflammatory process, which we knoAV the
part to be unable to bear ; and the part itself may be covered over with
tepid water-dressing, or any other bland protective application.
In the second, or inflammatory form—much the more frequent—our
object should be to subdue the local or perverted action, yet without
inpairing, on the contrary rather adding to, the general poAver of sys-
tem. The best local application with this view, is the nitrate of silver,
pencilled ovei' the red, painful, and swoln parts, so as merely to blacken,
and obtain the simply sedative and antiphlogistic result; covering the
part aftenvards Avith a light soft poultice, or water-dressing. The pa-
tient should be kept in the recumbent posture, with the part somewhat
elevated. The diet must be non-stimulant, othenvise action, already
beyond the poAver of the part to bear, will be further increased ; it must
yet be not truly antiphlogistic, or starving, othenvise both general and
local power, already weak, will be still further impaired, and the existr
ing action, even without increase, rendered more and more destructive.
It Avill consist, then, of simple farinaceous food; such as will maintain
power, and yet not favour undue vascular action. At the same time
the continued use of opiates is highly expedient. Great pain and gene-
ral irritation attend the progress of the disorder. The former is in part
ON MORTIFICATION.
215
alleviated by the nitrate of silver; both will be much assuaged by
opium, which further, according to some, would seem to exert a bene-
ficial tonic effect on the capillaries, thereby tending to increase vital
power under circumstances when it is much required. Under such
treatment, we expect, and often not in vain, pain, redness, and swell-
ing to cease, as also the advance of the mortification ; a healthy line of
demarcation is established ; the dead parts are thrown off; the patient
rallies greatly in his system ; and in short recovery is obtained, though
not of course without more or less mutilation.
But such was not the practice, and such Avere not the results of for-
mer times. The practitioner took but a one-sided view of the case ;
regarding deficient power alone, and overlooking redundant action.
His patient was literally crammed with diet of the most rich and stimu-
lant kind ; if in the better ranks of life, his table was made to groan
daily, as well as himself, under the most sumptous viands ; and yet
the generous food seemed only to feed the disease, not the patient.
The dusky redness spread more and more, and both part and frame
sank under it. The error Avas at length perceived, and an opposite
extreme was gone into. Seeing then nothing but over-action, antiphlo-
gistics were had recourse to, as if the process were of the ordinary
sthenic form; disregarding the want of power, Avhich did not fail to
increase under the neglect. Dupuytren, for example, trusted to vene-
section. Now, a middle place is wisely selected ; Ave neither stimulate
nor spoliate the system ; local action is moderated, while both local and
general power is enhanced and maintained ; and the result is altogether
satisfactory.
Local Applications in mortification.—-Local as well as general anti-
septics were at one time believed in ; and Avere of an alcoholic, tere-
benthinate, or otherwise stimulating nature. If employed previously to
the accession of gangrene, Avhile inflammation is still in progress, they
invariably prove injurious by hurrying on that action, already excessive.
During progress of gangrene towards sphacelus, all stimulation of the
part must still be prejudicial, for a like reason. When sphacelus is
complete, the stimulants acting on the surrounding living parts, which
are being sthenically inflamed for the purpose of effecting detachment,
are likely to aggravate such action to an injurious extent. As to their
effect on the dead parts themselves, it is either nugatory, or the reverse
of beneficial. For, hoAvever useful spirits of Avine or turpentine may
be in preserving parts already detached from the system, similar pre-
servation is certainly not Avhat we desiderate during the process of
separation; on the contrary, sloughs cannot be too soon removed from
the liAnng tissues. Local stimulants, therefore, improperly named anti-
septics, are not only useless, but hurtful.
Scarifications were also at one time in vogue ; usually with the view
of enabling the antiseptics to prove more effectual. If they merely im-
plicated the dead parts, they were inefficient. If they penetrated these,
and reached the living and inflaming stratum beneath, they obviously
did harm, as undue stimulants. Under only two circumstances are in-
cisions likely to prove beneficial in gangrene. First; when suppuration
216
PRINCIPLES OF SURGERY.
has freely occurred beneath a separating eschar, Avhich, being margin-
ally adherent, and itself incapable of the ulcerative process, induces all
the evils of tension and pressure on an acutely enlarging abscess; in-
cision through the eschar, under such circumstances, Avill afford infinite
relief—and it is not unfrequently thus required in cases of burn. Se-
cond ; when by free incision Ave may remove the cause of gangrenous
disaster, past, present, and impending; as in phlegmonous erysipelas;
and in diffuse cellular infiltration, whether of a purulent or urinous
kind.
During the formation and separation of the sloughs, light poultice or
warm Avater-dressing are the preferable applications ; as soothing, grate-
ful, and protective to the living parts. Often the latter may be advan-
tageously medicated, by solutions of the chlorides of lime or soda; at
first chiefly applied to the dead parts, as correctives of foetor ; after-
wards used, not only Avith this vieAv, but as a suitably stimulant lotion
for maintaining reparative energy in the living ulcer.
As the sloughs become detached, by the undermining process of
ulceration in the living stratum, they should be removed ; such removal
tending to diminish foetor, and the risk to the system by absorption of
the results of putrescence. If necessary, scissors are employed ; cut-
ting Avith these only in the dead part hoAvever; for, in affording assist-
ance to Nature in her detaching efforts, Ave should occasion neither one
moment's pain, nor the loss of a single drop of blood. Pulling rudely
at yet adherent sloughs, or cutting in living parts, is not unlikely to
re-induce the sloughing action ; more especially when the gangrene is
of the chronic form, and attended with general debility. After separa-
tion, both part and system are treated as in ordinary granulation ; only
with a fore-knoAvledge that, on account of previous exhaustion, support
will be soon demanded on the part of both.
The nitrate of silver Ave have seen to be very useful as an opponent
of the inflammatio debilis, in chronic gangrene. By some it has been
employed with another object in vieAv ; daring advancing gangrene;
applied intensely, to the sound part, so as to produce vesication, in-
flammation, and ulceration; instituting, as it were, a fictitious line of
demarcation; and attempting to dictate to Nature as to the point of
arrest. It need scarcely be said that the result has disappointed the
expectation. Nature is not thus to be schooled. Inflammation Avas
doubtless excited, but not of the sthenic type, Avhich alone can give
the ulcerative sulcus of separation ; but still of the asthenic and ex-
cessive kind, courting and hastening progress of the mortification.
Question of Amputation.
1. Amputation is not unfrequently advisable, in order to prevent the
occurrence of gangrene. Thus ; when a limb has been much injured
by mechanical or chemical injury—a severe compound fracture or burn,
for example—and it is apparent to the experienced observer that mor-
tification must ensue, involving the Avhole thickness of the limb, acute,
tending to spread, and from the first accompained by the most formida-
ON MORTIFICATION.
217
ble constitutional symptoms, amputation is performed above the injured
point; so soon as the primary shock has passed away, and the system
rallied so far as to afford sufficient tolerance of the operation.
2. When after such injuries gangrene has set in, of the acute and
spreading kind, there is now no question as to the propriety of imme-
diate operation. At one time, it was by many considered right, in this
and in all other cases of mortification, to Avait for the spontaneous line
of separation. But delay, under these circumstances, with such an
object in vieAv, will be in vain. The gangrene spreads upAvards and
upwards, Avith a diffused and streaky margin; the typhoid symptoms
grow more and more intense ; the trunk is reached, rendering operative
interference hopeless ; or, long ere this, the system has sunk, and the
patient perished. The only hope of escape, is by early amputation ; it
is a slender chance—for the probability is that the sinking may con-
tinue, or even the gangrene be resumed—but it is the only one, and to
it the patient is entitled. While the mortification is spreading, then,
AYe amputate at a distance from the gangrened part, in one Avhich is
sound, or at least appears to be so. If there be no point, distal to the
trunk, altogether free from the signs of incipient death, Ave refrain from
the knife ; its use must then prove futile, and Avould but accelerate the
fatal issue. And in making selection of the line of incision, when
amputation is advisable, it is Avell to remember that the subcutaneous
cellular tissue is often an earlier victim to the gangrene than the skin
itself; that therefore a point in the immediate vicinity of the discoloured
margin is never suitable ; and that in all cases careful manipulation
should be employed to ascertain, if possible, that all textures, as well
as the skin, are yet sound ; othenvise we might be cutting in parts not
only doomed but dead. Sometimes a case presents itself of acute trau-
matic gangrene, in Avhich there is yet even much space apparently
suitable for amputation, but in Avhich the constitutional depression has
advanced so far as to render the shock of an operation then performed
certainly fatal. In such circumstances our attention must be mainly
directed to rousing the vital poAvers, sustaining them under the depress-
ing agency; and if, thus aided, they fail in attaining to even a tem-
porary ascendancy, Ave refrain from operation.
3. In the chronic form of gangrene, arising without apparent external
cause, there is no such haste in the use of the knife. Nature's initiative
is calmly awaited. For until the line of separation has been formed,
we cannot knoAV how far the gangrenous conspiracy between action and
poAver has extended. If Ave amputate during progress, it is most likely
that we shall be cutting in parts fore-doomed; they had not poAver
enough to resist the inflammatio debilis, which was gradually creeping
on, and certainly will not for an instant Avithstand the graver amount of
action Avhich such formidable incisions must certainly excite. And,
further; even after the line of separation has occurred and is duly
advancing, it is probable that, local as well as general debility being
still great, the parts have just power enough to sustain the spontaneous
inflammation necessary for the ulcerative process, and would fall below
the stimulus of incision. Therefore, we Avait not only until the line of
demarcation has been made, and separation begun; but until the latter
19
218
PRINCIPLES OF SURGERY.
has been in a great measure completed ; assisting Nature's amputation,
rather than operating ourselves ; using our knife and saw merely to
divide the fibrous and osseous textures, Avhich are slow to ulcerate in
this Avay ; injuring the living parts as little as possible ; yet sloping the
knife upAvarcls, in order to have an opportunity of saAving the bone so
high as to afford a fair prospect of the stump proving sufficiently fleshy
and useful. In such cases, the system is very intolerant of loss of blood,
and that is another reason why incisions should be so guarded. There
is a circumstance, hoAvever, attendant on the disease, yery favourable
in this point of view. The dry, hard, impenetrable sphacelus, has the
same effect on the arterial tubes on its cardiac aspect as a ligature ; a
remora of their circulation is induced, coagulation takes place, and each
arterial canal is obstructed up to the nearest open collateral branch. As
the line of separation passes through, the canals are further and more
securely shut up by fibrinous effusion—such ulceration being of the
sthenic kind, and as usual preceded and accompanied by plastic exu-
dation. Even supposing, therefore, that our knife does encroach a
little on the living parts, higher than the line of spontaneous ulceration,
the hemorrhage is likely to prove but very trifling.
4. In the chronic gangrene Avhich is induced by cold—an obvious
external cause, and independent of constitutional vice or failing—we
still await the line of demarcation; for otherwise Ave cannot tell how
far the fatal amount of local depression has extended. But after sepa-
ration has been fairly and spontaneously begun, Ave do not hesitate to
amputate ; and with the option of either finishing Nature's operation
just commenced, or of cutting in a higher and perhaps more suitable
situation. For, the debility being only local, temporary, and not
dependent on organic change, the occurrence of the line of separation
is sufficient evidence that in every point of the living parts there is then
tolerance of operation. Usually a better stump can be fashioned at a
higher point than that which Nature has happened to select. ButAvere
such amputation to be made previous to arrest of the gangrene, most
probably the flaps Avould speedily slough.
Thus then, when gangrene is acute and humid, dependent on an ex-
ternal cause, and unconnected with a previously existing failing of
system or organic change in the general limb, Ave amputate, if at all,
during the progress of the disease, Avithout waiting for a line of demar-
cation. When it is chronic and dry, dependent on an internal cause
only, or on internal more than on external causes, and connected with
failing of both general and local vital poAver, Ave wait for the line of de-
marcation, Avatch the progress of separation—cautiously supporting the
system meanwhile—and when detachment is far advanced, Ave inter-
fere merely to facilitate and modify its completion ; we amputate in the
line of separation. When gangrene is the result of one particular ex-
ternal cause, cold, Ave await the line of demarcation ; and so soon as
that has been fairly formed, Ave amputate either there, or above, accord-
ing as circumstances may seem to require.
SECTION II.
PERVERTED VASCULAR ACTION IN CERTAIN TISSUES.
CHAPTER VIL
PERVERTED VASCULAR ACTION IN THE INTEGUMENT.
Erythema.
By th*i3 term is meant perverted vascular action, of a Ioav grade, and
tending to spread by continuity; occurring in the mere surface of the
integument; chiefly resident in the rete vasculosum cutis ; and seldom
if ever rising beyond the stage of active congestion.
The symptoms are heat, pain, and tingling in the part; a bright red
blush, sometimes marked by an abrupt and distinct border, sometimes'
gradually lost by diffusion ; more or less dryness, by interruption to nor-
mal exhalation; a very slight tumescence of the red surface, scarcely ap-
preciable by the eye, yet capable of being distinctly felt by the finger
lightly applied ; increase in susceptibility of external impressions in ge-
neral ; and tenderness on pressure, which produces transient Avhiteness,
and very slight as well as temporary depression. These symptoms having
continued for a day or tAAro, may simply decline ; the part becoming gra-
dually less SAvoln, red, tender, and painful, and resuming its Avonted func-
tion ; numerous scales of cuticle become detached, and fall aAvay ; and
the result is usually termed Resolution by desquamation. Or, less fre-
quently, vesication occurs ; the vesicles forming slowly, and to no great
extent; filled with a Avatery straAV-coloured serum ; either simply dry-
ing, or bursting and then crusting over ; the uneasy feelings thereafter
gradually subsiding ; and desquamation again constituting the last part
of the process of cure. The constitutional symptoms may precede or
accompany ; sometimes they are sthenic, and of the inflammatory type,
slight and transient—the consequence of the local disorder ; sometimes
they are of the form of constitutional irritation, preceding rather than
accompanying, and oftener the cause than the effect of the local ail-
ment.
The cause may be either local or constitutional, external or internal.
Often it is external and local; a puncture of the finger for example m
dissecting, nursing, Avashing, probably with a state of system not ill-
disposed towards the assumption of morbid action. The injured part
undergoes the inflammatory process; and this, instead of remaining of
a circumscribed character, spreads by continuity. The constitutional
220
PRINCIPLES OF SUIU1ERY.
disorder is then of secondary occurrence, slight, of the inflammatory
type, and soon passes aAvay.
Or the cause may be internal and constitutional. The prima? via}
are sadly disordered ; there is much bilious derangement, and serious
febrile disturbance ; during the progress of this febrile condition
an erythema breaks out on some part of the surface, spreading
more or less; and on its appearance the general disorder undergoes
a marked diminution ; it is, as it were, an example of Nature's mode
of relief by counter-irritation and derivation. Or the pajent is la-
bouring under a low typhoid fever, and during its progress an erythema
forms ; sometimes with relief—though not so marked as in the former
example—sometimes seeming rather to embarrass the system still more,
and increase the tendency to prostration.
The treatment varies according as the erythema is reckoned the dis-
ease itself; or only as a symptom of another, far more important. If
the cause be local and external, with constitutional disorder slight and
secondary, treatment is direct, as for the disease. The part is kept at
rest, and fomented ; or is lightly pencilled over either with a solution of
iodine, or with the nitrate of silver, either solid or in solution—the latter
probably the preferable application ; seeking only the first effect, black-
ening and non-vesicant, simply antiphlogistic. Antiphlogistic regimen
is enjoined, a purge administered, and perhaps a little antimony. Re-
solution is obtained.
If hoAvever the cause be internal and constitutional, with the general
symptoms formidable, and antecedent as Avell as concomitant, we seek
not resolution. As small-pox and scarlatina have their eruptions, are
relieved thereby, and become much aggravated by their repulsion, so
fevers—simple, bilious, typhoid—sometimes have theirs, of an erythe-
matous character; and the use of repellents is not more foolish in the
one case than in the other. Our principal attention will be directed to
the general disorder, contenting ourselves with palliation of the local;
occasional fomentation relieves the unpleasant feelings in the part, and
at the same time rather encourages the derivation than othenvise.
When Ave are especially desirous that a spreading erythema shall be
turned aside from certain parts, the nitrate of silver, still used lightly,
is of service ; not applied to the erythematous part, but in its vicinity;
not as a resolutive, but as a limiting agent.
Erysipelas.
Erysipelas denotes the inflammatory process, seated in the skin, and
sometimes in the subcutaneous cellular tissue as well; prone to spread,
and tending to the true inflammatory crisis. According to its seat, cause,
and general characters, the action exhibits marked variety in the symp-
toms and results; and various forms are in consequence enumerated.
We shall treat of the simple, phlegmonous, oedematous, bilious, and
erratic.
1. The Simple, or Cutaneous.—The morbid action pervades the en-
tire true skin ; and is more progressive than in erythema. The ordi-
nary symptoms, therefore, of such action, are more prominently deve-
ON ERYSIPELAS.
221
loped. The redness is greater ; often of a rosy hue, and hence the
vulgar name of the disease ; the sivelling is greater, appreciable by
both sight and touch ; the heat and pain are of a burning kind, and
often intense ; pale dimples by compression are more distinct and less
transient—though still soon passing away, by" refhcrof both circula-
ting blood and extravascular serous effusion. At firStTTlTere is "no acfy
tual tension ; the SAvelling is slight, gradual, serous, and soft. SomJ
times, however, Avhen the action is especially acute—the case perhaps
threatening to pass into the second form of the disease—SAvelling is
fibrinous, considerable, and rapid; and more or less tension occurs.
Ordinarily, as the moderate action steadily progresses, serous effusion
takes place superficially, elevating the cuticle by vesication ; sometimes
extensive and continuous, sometimes in the form of numerous small
vesicles. On the cuticle giving way, spontaneously or by puncture,
the serous fluid escapes, usually with relief to the symptoms. But not
unfrequently a similar effusion occurs on the internal as Avell as on the
external aspect of the cutis ; serum is infiltrated into the subcutaneous
cellular tissue, which, though originally free, noAV becomes involved in
the morbid process; and if the effusion be both copious and rapid, the
swelling becomes tense as ivell as much increased, and the symptoms
are aggravated thereby.
Very generally a strong tendency is evinced by the mucous mem-
branes, both of the respiratory and alimentary systems, to sympathize
with the cutaneous surface ; and not unfrequently, they seem to undergo,
simultaneously, a somewhat similar affection—and this Avithout me-
tastasis.
Like erythema, erysipelas may simply resolve. Or vesication occurs,
either alone, or along Avith gradual subcutaneous effusion ; the vesicles
burst, or are artificially emptied, the subcutaneous effusion is absorbed,
the symptoms abate, and the part quickly regains its normal state, by a
process Avhich may be still termed Resolution—by vesication. Such
recovery is not always uniform and general; it may be partial and suc-
cessive ; the part[firstattackejLbi^omingjrst_r(:>st'nrft^: while that more
recently invol^4jnTKeJine_of extension,is.yet in theZnaaHJHOnd
acute stage. Sometimes, however, the action does not recede though
vesication occur. " The vesicle bursts, and the serum is discharged, but /
simple desiccation does not iolloAvT1" A purulent discharge appears ; for j
the~action Has advanced to the grade of true inflammation. And not
improbably a similar formation may occur on the internal aspect as
well, either at the same time or subsequently ; causing subcutaneous
abscess. Such abscess only forms in the more intense or neglected
cases of simple erysipelas ; it is neither early nor diffuse as in the phleg-
monous form, but surrounded by the usual fibrinous deposit, and con-
sequently amenable to the ordinary treatment. Should incision be
delayed, however, sloughing of integument is not unlikely to follow ;
for the cellular tissue, having been previously infiltrated by acutely
effused serum, readily yields before the suppuration, so far as the limit-
ing fibrinous deposit permits ; the skin is early undermined, and, being
itself inflamed, with difficulty retains its vitality.
But suppuration, in simple erysipelas, is usually still more secondary.
19*
222 PRINCIPLES OF SURGERY-
After the ordinary symptoms have satisfactorily subsided, and almost
disappeared from the general surface affected, it is not uncommon to
find, in those especially of feeble constitution, that inflammatory reac-
cession of a more intense and circumscribed character has occurred aT
one or more~points"Tfthe part originally attacked ; in erysipelas of the
face, for instance, the JoAver eyelids often thus suffer. The returned
action is acute ; the part neAvly and imperfectly recovered from a pre-
vious inflammatory process, is vitally Aveak; in consequence, supp'ura-
tion is early and copious ; in the course of but a few hours a considerable
abscess may have formed. And it is under such circumstances that
sloughing of the integument is most especially probable, if the evacuating
incision be delayed.
The ordinary cause of simple erysipelas is external injury, often slight,
applied during a disordered state of system, favourable to inflammatory
accession. In most cases, therefore, the constitutional symptoms may
be said to precede the local; but the antecedent are not inflammatory;
they are either simply febrile, or, more frequently, those of stomachic
and biliary derangement; foul tongue, bitter taste in the mouth, head-
ach, tendency to shiver, thick turbid urine, sickness and bilious vomit-
ing, &c. On the occurrence of the local action, the general disorder,
as usual, assumes more or less of the inflammatory type; then gradually
subsiding, as both local action and its constitutional predisposing cause
yield to suitable treatment. When the local action is comparatively
slight, the antecedent constitutional disorder is often relieved by its
appearance, and can scarcely be said at all to acquire the inflammatory
type.
In some cases the cause Avould seem to be purely local. Then there
are no precursory general symptoms ; the constitutional disorder is secon-
dary, and of the ordinary inflammatory character. The light and gentle
modern treatment of Avounds is beneficial, as opposed to inflammation,
not only in favouring speedy reunion, but also by avoiding the risk of
such inflammation assuming the spreading or erysipelatous character.
Often the state of the atmosphere seems to exert a poAverful predis-
posing-influence in favour of the accession of erysipelas ; and hence we
not unfrequently find the disease assuming an epidemic foim, during
spring and autumn, Avhen atmospherj^jicissitudes most preA'ail. When
such is the case, we also find the constitutional symptoms, whether
primary or secondary, tending to show more or less of the asthenic
character ; the more especially as the majority of those attacked are of
already weakened frames, by dissipation, poverty, or previous disease.
Habitual exposure to heat, as in cooks, and furnace-men, predisposes
to erysipelas, by occasioning frequent sanguineous determination to the
surface. And frequent irritation of the skin, by friction or othenvise,
has a similar effect; as in sailors, by the rubbing of hard canvass
trousers, often saturated with the briny element of their vocation.
Exposure to cold, by its reactive effect, may predispose to erysipelas,
in those parts chiefly implicated—the hands and face ; as in coachmen.
But it is to be remembered, that in such cases, as well as in those of
habitual exposure to heat, other causes are in operation, especially in
the lower ranks ; namely, habits of intemperance.
When erysipelas has once occurred, both part and patient remain
ON ERYSIPELAS.
223
liable to its return, from the application of a comparatively slight cause ;
and are to be guarded accordingly. Many persons, particularly females,
are the subjects of regular periodical attacks, usually slight; but though
very amenable to the usual treatment, these are not to be rashly inter-
fered vvith ; their occurrence and ordinary course seeming to be a
natural relief from more serious impending disorder of the system.
Prognosis varies according to circumstances. The more extensive
the erysipelas, the more grave are the constitutional symptoms, and the
more serious the case. If situate on the face, head, trunk, or genitals,
it is more dangerous than on the extremities. If the constitutional
symptoms are both antecedent and concomitant, and of a marked
asthenic type, the case is one of danger. In early childhood and ad-
vanced age, the balance of life is very delicate, and easily turned;
erysipelas may operate much to the patient's disadvantage, and even
fatally. Previous habits of intemperance, atmospheric influence of a
sinister kind, exhaustion by previous disease, engender intolerance of
erysipelas, even Avhen apparently slight, and cloud the prospect of
speedy and satisfactory cure.
Treatment.—This must not be of the abortive or ectrotic character ;
Whether the disease be of local or constitutional origin. If the former,
sudden arrest is apt to be folloAved by sudden reappearance of the in-
flammatory process in another part—it may be in the integument, or it
may be in the lining membrane of an important internal cavity ; metas-
tasis occurs, and often unfavourably. If the former, natural relief to
an oppressed system is thwarted; constitutional disorder is not only
not relieved, as it should have been, but becomes perhaps seriously aggra-
vated. The treatment, then, will not consist of direct repellents, but
of such local means as favour gradual resolution; invariably accom-
panied, and if possible preceded, by search for and removal of the
apparent cause.
In most cases, as already stated, the predisposing cause is derange-
ment of the primse via. If an emetic be not otherwise contra-indicated,
it is an excellent commencement of practice ; unloading the stomach,
promoting the flow of bile, and usually inducing a profuse perspiration
from the general surface. It is followed by a purge, usually of a mer-
curial kind—say calomel and jalap—performing the same good office
for the bowels which the emetic has done for the stomach. The anti-
phlogistic regimen is enjoined ; and if the constitutional symptoms be
prominently sthenic and inflammatory, antimony is exhibited moderately.
If secretion in general, but more especially from the intestinal canal,
threaten to remain of a vitiated character, the list of alteratives is ap-
plied to ; and of these, the hydrargyrum c creta may be mentioned as
especially useful, in overcoming the obstinately dry tongue, and skin,
confined bowels, and scanty urine, with other signs of diminished secre-
tion, which very commonly are found after subsidence of the acute
stage of the disorder.
The local applications consist of warm fomentations, whereby the
ordinary antiphlogistic results are obtained ; the vulgar prejudice which
at one time existed against " wetting the rose," has long since subsided.
One mode of wetting is indeed highly prejudicial; that is, by cold,
221
PRINCIPLES OF SURGERY.
repellent lotions ; more especially Avhen the disease is so situated, aa
on the head, face, or trunk, as to render metastasis almost certain to be
an important locality. When the tenderness, heat, and pain of the
surface are especially great, the fotus may be beneficially medicated ;
as by acetate of lead and opium, in Aveak solution. In the slighter
cases, a comfortable sensation folloAvs dusting the part thickly over by
a li^ht and fine powder—as flour, or magnesia ; probably on account of
stimulus by atmospheric influence being thus removed; but in most
cases it is better to dispense Avith such an envelope, considering it to
be of much higher importance to maintain a constant and complete sur-
veillance of the varying condition of the part. To the minor examples,
the simply antiphlogistic use of the nitrate of silver is also applicable;
but it too is objectionable on the score of concealing the true state of
the part; and besides, it sometimes seems to have the effect of, as it
were, driving the action from the skin to the subjacent cellular tissue,
and so favouring suppuration there—as if inducing a metastasis from
the superficial to the deeper strata, and concentration there. We may
avail ourselves of its circumscribing poAver as in erythema; but its direct
employment we Avould consider as applicable chiefly to erythema, and
in erysipelas to the minor cases only; those, namely, Avhich have little
intensity of action, a limited extent, and are situate on the extremities.
Some, seeing the relief Avhich ordinarily attends on spontaneous vesica-
tion, have thought of imitating this by direct use of the nitrate of silver,
somewhat intensely applied ; the result of this additional stimulus to a
part already being inflamed, however, is not to subdue but to aggravate
the action.
Whenever the action is from the first acute, sthenic, and obviously
progressive, local blood-letting is advisable. For this purpose leeches
are often employed ; but they are apt to do more harm by the stimulus
of the AArounds—the suction of which seems to be inimical to adhesion,
and favourable to inflammation and ulceration, even a previously unin-
flamed part—than good by abstraction of blood. Punctures, rapidly
made with the point of a lancet, are preferable ; they are more painful
at the time, but the smarting soon ceases ; action soon declining from
approach to true inflammation, the Avounds usually adhere; and on
subsidence of the swelling, the cicatrices are so minute and faint as to
be almost or Avholly invisible. They are more efficient as antiphlo-
gistics than leeches, less apt to irritate, and seldom if ever leave any
mark at all approaching to deformity. They fulfil a twofold indication;
abstraction of blood, and evacuation of inflammatory effusion. The
majority are made to implicate only the rete vasculosum, their object
being loss of blood ; a feAv—and only a few such are necessary, the
cells of the areolar tissue freely communicating—penetrate more deeply,
to the subjacent cellular tissue; their object being to drain off the
serous effusion, so favouring vascular reliefj and at the same time pre-
venting the occurrence of untoward tension. Hot fomentation is assidu-
ously employed for some time after the infliction of the Avounds ; being
favourable to both indications. And if the sanguineous Aoav be not
altogether satisfactory, it may be increased by the temporary application
of a ligature on the cardiac aspect of the part.
ON ERYSIPELAS. 225
This practice by puncture may startle those who are practically un-
acquainted with it, by its apparent severity ; but the severity is only
ideal. We grant that in one point, the infliction of temporary pain, it
is more severe than leeching; but in every other, it is much and truly
superior. Alarming it may be to the timid patient; but it is quickly
over—a feAv seconds suffice—and the relief is both satisfactory and
instant. In the more severe cases Avhich demand its use, the pain of
infliction is often the least; the acute pain already existing in the part
masking that of the punctures ; in the same Avay that the operation of
scarifying tense and painful gums seems not unfrequently to be agree-
able rather than othenvise to the teething child. And, as already
stated, the ultimate cicatrix of each puncture is so trifling, as to render
the practice equally applicable to the face, AYhen erysipelatous, as to
any other part of the surface.
When abscess forms, whether during the acute progress of the dis-
ease, or of secondary occurrence, an early opening is highly advisable,
to save both skin and cellular tissue ; for although the abscess be not
diffuse, but someAvhat limited by fibrinous exudation, yet its tendency
to rapid extension is greater than in ordinary circumstances.
So soon as the action has begun to subside, there is often a necessity
not only for a discontinuance of general antiphlogistics, but for recourse
to tonics and support of the system ; as in the old or those of previously
debilitated frame, and sometimes Avhen the affection is of an asthenic
and epidemic character. Wine is given, at first cautiously ; Avith as
much plain nutritious food, as the stomach can easily digest. And be
it remembered that such tonic general treatment is, in such cases, not
incompatible Avith continuance or resumption of local antiphlogistics,
should these be demanded by the state of the part.
In all cases, after the inflammatory action has passed away, gentle
and uniform support by bandaging is expedient; preventing congestion,
removing the tendency to oedema, and hastening restoration to the nor-
mal sthenic condition. But this, and all other tonic treatment, Avhether
local or general, must be both cautiously begun and cautiously main-
tained ; being apt, if carelessly conducted, to prove excessiAre, and
induce secondary suppuration.
Mercurial inunction of the erysipelatous part has been loudly advo-
'cated. We are averse to all concealment of an inflamed part; and be-
sides, Avould dread an undue stimulus from the application, in the early
stage of the disease. By Velpeau, sulphate of iron is lauded as a local
application ; either in solution, an ounce to the pint of Avater ; or as oint-
ment, a drachm to the ounce of lard. Pressure is also a favourite con-
tinental remedy, from the first, and hoAvever acute the action; Avhen
gentle and uniform, it is very useful after subsidence ; but until then,
however carefully employed, it is more likely to aggravate than to
assuage the disorder.
II. The Phlegmonous, or Celhdo-cutaneous.—This is an infinitely
more serious affection. The action is intense, and rapid in its pro-
gress ; and a.plurality of tissues are involved from the first. The skin
and cellular tissue are both acutely inflamed ; liquor sanguinis is rapidly
exuded, and tension ensues; swelling is great and rapid; a limb, not
226
PRINCIPLES OF SURGERY.
unfrequently, is enlarged to twice its normal girth ; the skin is red, hot,
very painful, tight and shining—showing no rugae, but smooth and
glistening; pressure is very painful, and the part feels as if converted
into braAvn. Vesication often takes place, in a broad extended form,
as in the first effect of a blister; it is rather a favourable sign than
otherAvise ; for sometimes it betokens a subsidence of action. Hut
usually, by the tension, vascular action is farther increased ; and unless
speedy relief arrive, suppuration occurs. The pus is ill concocted—
not laudable, but thin and ichorous ; the parts are not protected by any
plastic effusion, but open and defenceless; infiltration takes place,
rapidly and extensively ; cellular tissue is broken up, ulcerates, and
sloughs; skin is undermined, and sloughs also. The ^ system sympa-
thizes largely ; inflammatory fever at first exists, often intense ; but on
the occurrence of destructive infiltration, a change is made to the form
of constitutional irritation, of a still more alarming character—probably
first shoAving the type of irritative fever, then that of hectic, ultimately
that of prostration and collapse.
But the disorder, and its effects, are by no means limited to the tex-
tures primarily involved. Suppose the case to be both intense and
neglected. The inflammatory action spreads by contiguity as well as
continuity, and that rapidly. Fascia is involved, and sub-fascial cel-
lular tissue; the tension Avhich results from this is greater and more
serious than from merely subcutaneous infiltration; and the action is
proportionally aggravated. Intermuscular cellular tissue is implicated,
and muscles are detached by its disruption ; periosteum inflames, and
suppuration—still diffuse—takes place beneath it; bone inflames and
dies; joints are opened into, inflame, and suppurate; and inflam-
mation, diffuse suppuration, and sloughing, having at length more or
less involved almost every texture of the limb, the suffering frame may
demand amputation to save life; or death may ensue, ere ever an
opportunity for operation occur. Such fatal issues are not unfrequent;
but still more common are stiff joints, necrosed or carious bones,
withered limbs, and Avasted frames—the results of ill-treated phleg-
monous erysipelas.
The constitutional symptoms Avhich attend on this grave malady are
of three kinds. 1. Of a bilious character, as in most examples of the
simple form, preceding and ushering in the local disorder. 2. Inflam-
matory fever, during the rise and progress of the inflammatory process.
3. Constitutional irritation ; the suppuration having formed, and by
infiltration advancing rapidly in its devastating progress. The causes
are similar to those of the simple form.
Treatment.—This, in the first instance, must be mainly constitutional,
as in the simple. Emetic, purge, antiphlogistic regimen, antimony,
and perhaps venesection. Were our object simply to overcome an
intense inflammatory process hastening on to dire results, Ave should
bleed always ; but Ave know that in many cases the sthenic stage is but
brief, the asthenic early and serious—more especially when the disease
is of an epidemic character; and that in all cases, if the action be not
arrested in its very rise, suppuration and infiltration are inevitable, and
certainly followed by constitutional symptoms tending to the lowest
ON ERYSIPELAS?.
227
type. Only at the very commencement of the case, then, in patients
previously robust, and Avhen the symptoms hitherto have all indicated
the sthenic character, is the highest antiphlogistic remedy, general
bleeding, advisable ; and even in those cases in Avhich it is expedient,
it must be practised with a cautious economy of the " liquid living
flesh"—for, as in compound fracture and other severe injuries followed
by inflammation, hoAvever acute and sthenic the action may be at first,
a long day of trial to the system by debilitating causes may be fast
and surely impending. In very many cases, our aid is not demanded
until the period for active local treatment has arrived ; and then local
bleeding, which is essential, can be made to have a constitutional
effect.
We have the high authority of Mr. Liston for considering aconite
and belladonna useful, in small doses, during the acute stage ; begin-
ning with the former, and giving half a grain of the recent extract
either in substance or in aqueous solution, repeated every third or
fourth hour; it is said to diminish arterial force, produce perspiration,
and by lessening action to mitigate tension and the other urgent local
symptoms. Then to prevent reaction, the extract of belladonna is ad-
ministered, in the close of a twelfth of a grain, repeated at similar inter-
vals. I have to confess to no experience of this ; and farther, to being
quite satisfied with the ordinary antiphlogistics, even in the most acute
cases,—blood-letting, purging, opium if necessary, and the antimonial
solution.
The affected part is placed at rest, elevated, and with its muscles
relaxed. At first, the most suitable application is hot fomentation ;
and under this, with appropriate constitutional treatment, the case may
resolve. More commonly, hoAvever, the action advances, swelling
rapidly increases, and tension Avith aggravation of pain ensues ; liquor
sanguinis—not serum, or serum principally, as in the simple form—has
been effused; if the action progress farther, the effusion will rapidly
degenerate into an ill-conditioned pus, Avhich will be Avidely infiltrated
into the defenceless texture around ; the cellular tissue is doomed, the
existence of the integument has groAvn precarious, and constitutional
disaster is inevitable. This then is the period for action; a period
both early and brief. The effusion must be permitted to escape, and
loss of blood, copious and direct, is necessary to arrest the advancing
action. Punctures evacuate serum readily enough, and the loss of
blood which they occasion is sufficient to allay an inflammatory process
of no great intensity ; they are consequently very suitable in simple
erysipelas; but for the phlegmonous, they are altogether insufficient.
Punctures are superseded by incisions ; the lancet by the scalpel or
bistoury. Through the incision, liquor sanguinis drains aAvay, ere yet
it has degenerated,, or while it has just begun to do so ; blood is drawn
rapidly and in sufficient quantity to arrest the local action, at once
limiting farther effusion, and preventing degeneration of this from in-
flammatory action ; and the effusion, comparatively slight, which does
continue, has no opportunity to infiltrate, but at once finds a ready
access to escape. This is the true time for incision ; saving disruption
and sloughing of cellular tissue, danger to skin, and serious disorder of
228
PRINCIPLES OF SURGERY;.
system ; while the action is yet comparatively recent, and just in the
act, as it Avere, of surmounting its true inflammatory crisis ; Avhen the
part is tense, red, shining, painful, throbbing, and feels like brawn.
At a subsequent period, Avhen suppuration has occurred, and the deadly
infiltration of purulent fluid begun, incision is demanded with equal, or
even greater urgency; but its object is Avholly different; too late to
save tissue and prevent disaster; in time only to mitigate, and perhaps
limit, destruction already done. The knife, Avhen used at the proper
time, need not go deeper than the subcutaneous cellular tissue; the
action and its results have as yet extended no farther. Butwhen used
at a later period—too late to prevent mischief, and only in time to
limit—it must perforate the subjacent fascia as Avell; in fact, it must
reach all the infiltrated textures, otherwise it might almost as well be
altogether omitted. This therefore is another argument in favour of
early incision.
The treatment of phlegmonous erysipelas by incision, may be said
to be as old as the surgery of the 16th century, according to Prospero
Alpini;'but its true introduction into practice is comparatively recent,
by the exertions of Mr. Copland Hutchison and others. It seems a
severe remedy; and doubtless so it is. But it seems more cruel than
it really is—the Avound looks both wide and deep at the moment of
infliction, but in a few days, sometimes after but a few hours, subsi-
dence of the swelling may have reduced it to a comparative scratch;
and besides, even though it Ave re altogether as severe as it seems, no
other proceeding will prove equally efficacious; ad extremos morbos,
extrema remedia. There is now hardly any question as to the propriety
of free incision after suppuration has occurred ; there is no other means
of sparing both part and system. But some are not fully persuaded of
the justice and expediency of the practice, at the earlier period, when
the infiltration is only as yet of liquor sanguinis, and Avhen the action
has not yet reached its crisis. But Ave think, that a due consideration
of the indications which such treatment comprises, and the paramount
importance of the fulfilment of such indications, is not unlikely to
reconcile them to the seeming cruelty.
At one time, also, it Avas matter of dispute, among those Avho favoured
the practice of incision, Avhether the Avounds should be long or short.
Whether the knife should be entered at the upper part of the inflamed
texture, and carried doAvn continuously throughout its Avhole extent,
however great that may be ; or Avhether it should be applied only to
those parts most implicated, Avhere tension and pain are greatest, and
infiltration and suppuration most imminent. Seldom if ever is the
Avhole part equally affected ; some points of the surface—perhaps the
greater number—may show only the characters of simple erysipelas, or
little more, Avhile in others the phlegmonous symptoms are in active pro-
gress ; by the latter only are incisions demanded. Consequently we
find that common sense and common practice have decided in favour
of the " short cut" system; and no longer, as has been Avell observed
by Professer Cooper, are yard-measures required for ascertaining the
extent of incisions in erysipelas. To enter a knife over the great tro-
chanter and withdraw it only when it has reached the knee, or not
ON ERYSIPELAS.
229
until even the outer ankle has been approached—as has been done—is
to inflict a very serious Avound; much loss of blood, shock to the sys-
tem, and protracted suppuration; Avhich triumvirate, becoming asso-
ciated with the exhausting effect of the natural progress of the disease,
is not unlikely to overpower the system. A few small wounds, im-
plicating only those portions of the texture Avhere their presence is es-
sential, are not only much less serious as an additional mechanical injury,
but more effectual as a remedy.
The hemorrhage is direct and copious ; and is permitted to continue,
until sufficient shall have flowed for satisfactory evacuation of the part;
and, as formerly stated, in many cases the loss is carried a step further,
so as at the same time to afford a sedative result upon the system.
Should the Aoav threaten to prove excessive, the part is elevated, and
pressure temporarily applied on the bleeding point or points, either by
the finger, or by lint and bandage. It is very seldom that any vessel is
wounded of sufficient size or activity to require a ligature. In some
cases, Avhen Ave have hazardous local action, Avith much impairment of
general power, Ave are constrained to incise, and yet very loth to shed
blood ; in such circumstances, the Avound will be as limited as possible
in both extent and depth, and temporary pressure, with elevation of the
part, Avill be had recourse to, almost immediately after the infliction.
After bleeding has ceased, pressure—if employed—is Avithdrawn, and
fomentation resumed ; and during the intervals of fomentation, a light
warm poultice is applied to the Avhole inflamed surface ; favouring extra-
vascular exudation—Avhich is noAV harmless, because readily escaping
so soon as formed, and not accompanied by true inflammation ; and ex-
pediting subsidence of the Avhole action. The Avound itself inflames
and suppurates, and not unfrequently a thin ash-coloured slough coats
its margins ; but the surrounding cellular tissue retains its integrity ; its
anormal liquid contents gradually exude ; SAvelling falls rapidly; redness,
pain, and tension all disappear. This resolutive process Avill be
found far advanced in the course of tAvo or three days; and then, both
fomentation and poultice, but especially the latter, are to be discon-
tinued ; to employ them longer Avould be to render certain the occurrence
of those untoward relaxing and suppurative results formerly stated. The
fomentation is altogether laid aside ; and instead of poultice to the Avhole
surface, tepid Avater-dressing is applied merely to the wound or Avounds,
and changed as often as the discharge—at first usually profuse—renders
necessary on the score of cleanliness. To the general surface early
support by uniform bandaging is expedient, for like reasons as in the
simple form, but more urgently demanded ; at first, let the application
be especially gentle, otherwise the stimulus of pressure, coming with
the support, may reinduce vascular action ; and in those cases in which
suppuration has occurred, cellular tissue sloughed, and skin been to
some extent undermined, caution in bandaging is most necessary
throughout, otherwise injury may be done to vessels more or less iso-
lated °by the destruction which has raged in the common textures
around. At the same time that local support becomes expedient, so
does support of the system ; and in many cases of the phlegmonous, as of
the simple erysipelas, the general tonic system of treatment is required
2S0
PRINCIPLES OF SURflERY.
at an earlier period, while, local antiphlogistics are still in use ; general
support and local depletion being by no means incompatible.
The wounds, on subsidence of the general swelling, shrink greatly
in their dimensions; and, as both part and system recover tone, dis-
charge diminishes, and healthy granulation advances. During separa-
tion of the superficial sloughs, water-dressing is applied ; after separation,
this is more or less medicated, as the character of the granulations may
seem to require. Not unfrequently there is a tendency to great exube-
rance of granulation, delaying the cure, and producing an unseemly
bulging cicatrix when that is at length obtained ; this is best obviated
by early adoption and due maintenance of Avell arranged pressure.
There is the same necessity for guarding against the occurrence of
secondary abscess, as in the simple form.
Phlegmonous erysipelas has sometimes been thought to be con-
tagious. On this subject, however, opinion is found greatly to vary.
And during the unsettled state of the theoretical question, it is well to
keep on the safe side in practice, by treating the disease, especially in
hospital, with every precaution against communication.
Not unfrequently it is complicated with other maladies, also of a
serious nature. Phlebitis and inflammation of the lymphatics seem to
own the same predisposing and exciting causes ; the predisposing being
constitutional disorder of a bilious character, sinister atmospheric in-
fluence, or both ; the exciting—Avounds, and other mechanical injuries,
more especially when treated unskilfully.
III. Oedematous Erysipelas.—This is a low grade of action in a Aveak
system ; and the same textures are involved as in the phlegmonous
form. True inflammation is not reached ; and the characteristic effu-
sion is that of serum in the subcutaneous cellular tissue. Swelling is
great hut gradual, soft, and pitting deeply and durably on pressure.
There is no tension, little heat or pain, itching rather is complained of,
and the redness is of a pale hue. The extremities, especially the lower,
are the parts most frequently affected. The constitutional symptoms
are but slight; there is obvious derangement of health, more of the
asthenic than of the sthenic character, yet scarcely referrible to any
peculiar type.
Treatment.—Punctures are advisable, but they need be few in num-
ber ; for, slight loss of blood will suffice to moderate the action, and
not many apertures are necessary for effectually draining off the serum.
For a day, or so, fomentation is employed, and"then uniform bandaging
is had recourse to—at an earlier period, and more preservingly main-
tained, than in any other form of erysipelas ; there is little risk of rein-
ducing action, and stimulation of the absorbents is the paramount indi-
cation. At the same time, diuretics will probably be expedient, as in
other examples of serous effusion. General disorder of secretion may
require alteratives; withal a tonic system of treatment is to be main-
tained, and sometimes it requires to be rather actively pursued as soon
as subsidence of the local action will admit of this.
_ IV. Bilious Erysipelas.—This term is applied to those cases of Ery-
sipelas, in which the symptoms of biliary derangement not only precede
local action in a marked form, but are'throughout the whole progress
ON ERYSIPELAS.
231
Of the case of a very prominent character. Either simple or phleg-
monous erysipelas may be so characterized ; but the former by far the
more frequently; in truth the local action is usually slight, seldom
reaching suppuration; and the constitutional symptoms also partake in
but a slight degree of the inflammatory type. The more prominent
general symptoms are headach, nausea, bilious vomiting, pain or weight
at the epigastrium, thirst, loathing of food, eyes and face suffused, ge-
neral hue yelloAV, sclerotics especially discoloured, foul dry tongue, and
a bitter bad taste in the mouth, bowels constipated, urine scanty, and
depositing a copious turbid sediment. Locally, the ordinary signs of
the inflammatory process are but slight, and the redness is almost
merged in the prevailing yellow discolouration of the integument.
The treatment will be mainly of the constitutional kind; emetics,
purgatives, alteratives, diuretics and diaphoretics, as circumstances
require ; and on these the practitioner is mainly to rely for cure of the
local as Avell as of the general symptoms. Treatment of the part is
but a secondary matter: and is slight in proportion to the action for
Avhich it is demanded; fomentation, rest, bandaging ; seldom abstrac-
tion of blood.
V. Erratic Erysipelas.—The peculiarity of this form is the tendency
to shift from one part to another; not extending merely, and occupying
a larger space, as the simple erysipelas does : nor leaving one part sud-
denly to reappear at another somewhat distant, as any form of the dis-
ease may do ; but leaving one part for another, and yet maintaining the
extension continuous and unbroken. The action is invariably slight;
often little more than a mere erythema. The occurrence is almost uni-
formly indicative of a feeble and impaired system. The constitutional
symptoms are ahvays antecedent as well as attendant, of the asthenic
kind, and if not actually typhoid, tending manifestly thereto.
The treatment accordingly has little to do with the affected part.
Fomentation and rest suffice ; and if the spreading be in an unfavour-
able direction, as towards the face or scalp, it may be diverted into
another course by the use of nitrate of silver as a limiting agent. The
system mainly occupies our regard. Alteratives, tonics, stimuli, are
given as required. When sinking has fairly threatened, in addition to
the ordinary means of support, turpentine, given by both mouth and
rectum, will be found an excellent remedy.
Hospital Erysipelas.
This term is often applied to the disease, in all its forms, as occur-
ring in hospital practice ; the patient not being admitted labouringun-
der the affection, but seized by it Avhile resident Avithin the institution,
on account of other ailments. The phlegmonous form is usually most
frequent under such circumstances. And if the cases prove numerous,
either the disease will be found at the same time prevalent out of doors,
untoward atmospheric influence conspiring thereto; or some serious
fault will be apparent in the hospital^management, as regards ventila-
tion, dressing of sores, and bestowal and arrangement of patients. The
chief peculiarity of hospital erysipelas is, that usually the asthenic type
232
PRINCIPLES OF SURGERY.
prevails, even in the most urgent cases ; and that consequently, as a
general practice, energetic spoliative and depressing antiphlogistics are
not advisable in the treatment.
Our attention is to be chiefly directed toAvards prophylaxis. The
number of patients in one Avard should be feAY ; and those with foul
running sores should be carefully segregated. The sores should be
dressed lightly and simply, avoiding all stimulating acrid applications,
lest, over-action folloAv, and the spreading or erysipelatous character
supervene. No sponges should be permitted to appear within the
wards ; and every possible means should be taken to avoid community
of dressing, and contamination of sores. Dressing is to be renewed as
often as cleanliness demands; not unnecessarily, lest the sore resent
and inflame ; not too seldom, otherwise pus accumulates and putrefies,
irritating not only the sore and its vicinity, but polluting the Avhole at-
mosphere of the ward, and injuring all its occupants. Ventilation and
general cleanliness of the apartments are also most essential. And, as
formerly stated, it is well to use all precautions, as if the disease Avere
undoubtedly contagious.
Thus then we find the general characteristics of the erysipelatous in-
flammatory process, in its more marked forms, to be; tendency to
spread ; tendency to change its site by metastasis ; tendency to prevail
in an epidemic form; deficiency of concomitant fibrinous and plastic
effusion ; rapid attainment of the suppurative crisis; the pus, as if im-
perfectly concocted, thin, and non-laudable ; by its diffusion, danger to
texture great; in the constitutional symptoms, the inflammatory type
seldom predominant; tendency to the asthenic character usually strong,
often even from the first; gastric and biliary disorder, with general
derangement of secretion, primary and great; active local treatment not
advisable when texture is not in danger, but Avhen diffuse suppuration
is either threatened or established, free incision alone remedial; active
constitutional antiphlogistics in few cases well borne, unnecessary ex-
cept in the most sthenic and intense examples, and even then to be
employed with much prudence and moderation ; in the majority of
cases, and at a comparatively early period in all, constitutional support
on the contrary demanded. In short, an asthenia, or tendency thereto,
reigns throughout; and by some this is accounted for by supposing a
poisonous influence to be exerted on the system, either generated with-
in, during and by the inflammatory process—or conveyed from without,
by atmospheric influence or by direct contagion.
HOSPITAL GANGRENE, OR HOSPITAL SORE.
This was at one time a scourge of hospitals, both in civil and in
military practice, especially in the latter; but since both the treatment
of sores and management of hospitals have much improved, of late, it
ON HOSPITAL SORE.
233
is of comparatively rare occurrence; and Avhen it does appear, it sel-
dom evinces those formidable and intractable characters Avhich formerly
used to carry devastation and death.
It seems to have been known and described by the old Avriters, as
CEtius, Paulus, and Avicenna ; but Avas not noticed, prominently and
distinctly, till during the late Avars, in the end of the last century and
beginning of the present. Then, from the crowding of wounded men
in hot, dirty, and confined apartments, perhaps after long and rough
carriage, with bad food, mental depression, and insufficient attention to
dressing and cleanliness, foul degeneration of sores became not uncom-
mon ; and Hospital gangrene came forth in all its virulence—as the
graphic pages of Hennen, Blackadder, and Boggie, sufficiently testify.
Within these feAv years it made its appearance in the Surgical Hos-
pital of this city ; in a slight form ; and obviously attributable to insuf-
ficient ventilation and purification of the Avards. Suitable attention to
this, and temporary removal of the patients, sufficed for its removal.
The disease is an example of sloughing phagedgena. It may be pro-
duced directly by contagion, more indirectly by infection ; or it may
occur independentry~oieiTIier—from croAvding, evil dressing, or nox-
ious atmospheric influence. Mercurialism is especially favourable to
its accession. It may either seize on a wound already existing, or ap-
pear in a pajt_Pi'eviously entire.
On an unbroken surface, the"first appearance is usually either a pustule
orvesicle ; small, dark, and accompanied with sharp stinging pain. On
the giving way of the cuticle, a slough is formed ; and this continues to
extend both in surface and depth. After a time the slough begins to
separate ; but Avithout arrest of destruction in the part, this being con-
tinued by acute phagedaena, often with greater and more unremitting
pain than before ; then sloughing appears ; and so the Avork of local
death advances—invariably accompanied with profuse, foetid, and thin
discharge. Sometimes the progress is so rapid as to cover a large
space Avithin a feAv hours ; in other cases, the advance is reckoned more
conveniently by days than hours. The ulcerous cavity is ofa tifcular
form, as if scooped out by an instrument. The edges are jagged, and
evertejL Avell defined, and often studded with red points of'a peculiar
appearance, said to be characteristic of the disease. The lymphatic
glands are apt to become aflected"at~an early period ; they enlarge, sup-
purate, open, and the ulcer is prone to assume the same action as the
original sore. The surrounding parts are savoIu, red, tense, painful,
and of a darkjiyid hue J~and this inflammation is apt not to remain
limited, as amere antecedent to the local death, but to spread, and
add the serious complication of erysipelas to the original malady. _ And
thus hospital erysipelas and hospital sore may be found to co-exist.
When a wound is attacked—as is most frequently the mode of ac-
cession—it first inflames, and the pain is severe, the patient complain-
ing as if wounded there byjtnjnsect; discharge is diminished, or may
beTforaTimeaTEogether arrested: Then the granulating surface rapidly
changes, assuming a dirty white colour; and sometimes becoming
spongily_elevatejLand cregifangTFair, the product of putrescence.
The surrounding skin swlIETaSS^soTa purplish hue. Slough forms,
234 PRINCIPLES OF SURGERY.
either in one continuous mass, or in detached portions. The dead
matter begins to separate, but not by a healthy process ; the edges
harden, evert, remain of a dirty Avhite appearance, and^ pour out much
foetid discharge—very different from the healthy pus Avhich escaped but
a feAv hours before. Sometimes the body of the sore has not the gray
or Avhitish colour, which usually obtains, but is dark from the begin-
ning, the sloughing parts being infiltrated and mixed up Avith putrid
extravasation. The degeneration generally commences at the edges,
but rapidly invests the whole; and the continuance of the malady is
also chiefly marginal. -
The constitutional symptoms, in whatever way the local malady may
have made its attack, "are invariably formidable—constitutional irrita-
tion, typhoid, and tending to collapse. As in erysipelas, they some-
times precede and usher in the local change ; sometimes they are only
consecutive and attendant; when antecedent they are ahvays aggra-
vated by the occurrence and extension of the local disorder—an event
not invariable in erysipelas. _ In some very few cases, when the pa-
tient was just before robust and in rude health, and has suffered by
direct contagion, the introductory constitutional symptoms may be of
the inflammatory type ; but even then, these will be very transient, and
soon become merged in irritation. More frequently the commencement
is with irritative fever, this glides into the confirmed typhoid, and sink-
ing folloAvs. Along with the corporeal depression comes mental de-
spondency—" The bravest soldier betrayed a symptom which, in those
of less strength of mind, formed a striking feature in every stage of the
disease ; namely the greatest imaginable impatience of pain, and de-
pression of spirits. Those who had borne amputation without a groan,
shrunk at the washing (?) of their sores, and shuddered at the sight of
a dead comrade, or even on hearing the report of his death; instantly
predicting their own dissolution, and sinking into sullen despair."*
No texture is proof against the ravages of this disease. The arterial
resists longest, but in the end gives Avay ; and hemorrhage ensuesT^FoF
therein not, as in ordinary ^gangrene, more espl^iaUyjjyhen offlie
chronic kind, the_solidifying of the arterial extents', with occclusion of
the canatup to the~nearest collateral branch. The"deathjs rapid, and
the slough peculiarly humid and soft j circulation^'though feeble, goes
on till sphacelus is complete; and besides, it is probable that the
blood's power of coagulation has been much impaired, as happens in
other examples of poisoning of the system. This bleeding may be
favourable, as formerly stated, if only to such an extent as .to affect the
part—resolving the inflammation which precedes and leads to the local
death; more frequently it is profuse and prejudicial, increasing the
prostration, and hastening the fatal issue. " The third and last stage
was now fast approaching. The surface of the sore was constantly
covered with a bloody oozing, and, on lifting up the edge of the flabby
slough, the probe was tinged with dark-coloured grumous.blood, with
which also its track became immediately filled ; repeated and copious
venous bleedings now came on, which rapidly sank the patient; the
* Hennen's Military Surgery, p. 219.
ON BOIL.
235
sloughs, whether falling off spontaneously, or detached by art, were
quickly succeeded by others, and discovered on their removal small
thickly-studded specks of arterial blood. At length an artery sprung,
which in the attempt to secure it, most probably burst under the liga-
ture ; the tourniquet or other pressure, Avas now applied, but in vain ;
for while it checked the bleeding, it accelerated the death of the limb,
which became frightfully swelled and horribly foetid. Incessant retch-
ings soon came on, and with coma, involuntary stools and hiccough,
closed the scene."*
Or instead of advancing to a fatal issue, recovery may take place.
In this country, and at the present day, this is the general rule ; death,
and even much local destruction, form the exception. The constitu-
tional disorder gradually abates ; pain diminishes, and the inflammation
of gangrene is succeeded by that of arrest; sloughs separate, and are
neither reneAved, nor supplanted by phagedaena ; the discharge becomes
less copious, thin, and foetid, more purulent and laudable; granulation
and repair are established. But such amendment is not to be reposed
in implicitly ; anxious care is yet requisite ; for relapse is by no means
unfrequent.
Treatment.—As in hospital erysipelas, prevention is the chief object
of the practitioner; and is to be obtained by similar means. When the
disease has occurred, the treatment is of that kind formerly recom-
mended for sloughing phagedena in general. Locally, escharotics,
efficiently applied, and repeated if necessary ; followed by poulticing or
water-dressing, until sloughs separate, and healthy granulations appear.
By the chlorides of lime or soda, the foetor may be corrected. Consti-
tutionally, gentle yet effectual cleaning out of the primae viae, calma-
tives, anodynes, if need be stimuli. Bleeding or other poAverful
antiphlogistic remedies, are never Avarrantable ; and mercury is to be
avoided as a poison. On arrest of the local action, the constitutional
disorder often voluntarily subsides.
FURUNCULUS, OR BOIL.
This is a limited inflammation of a small portion of the skin and cel-
lular tissue, ending in death of the latter, and accompanied by laudable
suppuration ; always of the sthenic type. It is not a mere pimple ; for
that is but inflammation and suppuration of an obstructed sebaceous
follicle. Nor is the term to be regarded as synonymous with carbun-
cle ; for that is more extensive originally, liable to spread secondarily,
and both generally and locally asthenic throughout, sometimes, nay
frequently, bringing life into serious peril. Whereas the boil is not
only sthenic in Itself, but rather indicative of a robust and plethoric
system; at all events, the attendant constitutional disorder partakes
more or less of the true inflammatory type, and requires to be treated
accordingly.
* Hennen's Military Surgery, p. 220.
236
PRINCIPLES OF SURGERY.
The affection is most frequent in the young and middle aged, and in
those ayIio eat freely, and are liable to stomachic and hepatic derange-
ments. The most common site is Avhere the skin is thickest—and per-
haps most removed from abstergence and ablution—on the back, shoul-
ders, hips, back of the neck and thighs.
Boils seldom occur singly, but are gregarious. The SAvelling is of a
conical shape; its apex yelloAV ; its base hard, red, and exquisitely
painful. The pus is superficial; the slough is at the base. Sometimes
the slough, or core, as it is commonly termed, consists only of cellular
tissue ; sometimes a portion of the true skin is implicated; not unfre-
quently an addition is given to its bulk by commixture with fibrinous
exudation. If left to itself, the boil bursts at the apex, and the matter
escapes by a single aperture ; sometimes this is sufficient to permit a
free passage to the slough A\-hen loose ; more frequently it is insufficient
for this purpose. On purulent discharge taking place, the pain, heat,
and surrounding SAvelling usually abate ; but subsidence is not complete
until slough as Avell as matter has been extruded ; the former, so long
as retained, acting the part of a foreign body, and maintaining per-
verted vascular action.
The predisposing cause is derangement of the primae vise, and con-
sequently of secretion in general. The exciting, is some direct sti-
mulus of the part; as by a prick, scratch, or evulsion of a hair. Not
unfrequently, no exciting cause exists; the predisposing alone is
sufficient.
Treatment.—During the nascent condition of the inflammatory pro-
cess, fomentation is used, with Avater-dressing or poultice. On sup-
puration having occurred, an incision is made in the apex, sufficient
to insure discharge not only of the pus, but of the slough also; if an
opening already exist, it is dilated for the like purpose. The part is
kept at rest; and after ejection of the slough, the granulating wound is
dressed in the ordinary way. The constitutional treatment—not the
least important—consists of purgatives folloAved by alteratives, to
cleanse and rectify the primae viae ; and someAvhat of the antiphlo-
gistic regimen should be enjoined throughout the whole process of
cure. To prevent relapse, experience speaks in favour of two very
opposite remedies, alkalies, and mineral acids ; the liquor potassae, and
the dilute sulphuric acid ; given in small doses three times a day, and
continued for a considerable period. In each case the ordinary gastric
indications will determine Avhich class of remedy happens to be the
more suitable.
ANTHRAX, OR CARBUNCLE.
This is more extensive and altogether more important than the pre-
ceding. Inflammation of an asthenic type attacks the cellular tissue;
and this sloughs at an early period of the invasion; the super-imposed
skin is secondarily and less involved, becoming gangrenous only to a
comparatively less extent, and not continuously, but°usually in small
ON CARBUNCLE.
237
unconnected patches. Through the openings thus formed, a foetid
sanious pus oozes out, with portions of sloughed and disintegrated cel-
lular tissue. The general SAvelling is flat, dark, and spongy; a dull
burning pain is felt in the part, and in the early stage is much increased
by pressure ; the surrounding integument is livid, painful, and SAVoln.
Carbuncle is usually found in the same situations as furunculus ; but
unlike it is generally solitary. It may vary in size from that of a prune
to that of a soup plate. The progress is usually slow ; ordinarily limited
to the surface ; but sometimes the deeper parts are also involved, so
as to expose cavities, canals, and bones.
The constitutional symptoms are asthenic throughout; at first of a
simply febrile and bilious character ; then showing typhoid signs ;^ and,
as the hidden gangrene extends, tending rapidly towards prostration—
more especially in the old—with hiccup, cadaverous countenance, fee-
ble pulse, delirium, and coma.
The disease most commonly occurs in those of middle age, or further
advanced in life ; and especially in those who have indulged freely and
habitually in the pleasures of the table. It is not contagious. The
constitutional symptoms invariably precede. The local change begins
with a hard painful swelling, mainly subcutaneous, which rapidly en-
larges, with dark discolouration and burning pain ; vesicles form on
the skin; and on the cuticle giving way, the sloughy apertures of the
skin are disclosed, as formerly described.
Treatment.—Tree and early incision is to be made, usually of the
crucial form, throughout the whole extent of the diseased mass ; this
evacuates the purulent formation, affords an exit for the sloughs when
loose, and limits infiltration. But this is not enough. Potassa fusa
follows the bistoury, and is used freely ; by it the dying parts are at
once converted into a dead eschar, healthy separation is accelerated,
and injury of the system from absorption of the deleterious products of
humid putrescence is almost at once arrested ; and, further to ensure
fulfilment of the last indication, the slough, as it loosens, is to be care-
fully removed by knife or scissors. The practice seems severe, but no
other will prove in all respects successful; and the more advanced the
case, the greater the necessity for its adoption. Less pain is occasioned
than might be supposed, the greater part of the cauterized tissues being
already in a gangrenous state. Poultice is applied till the slough is
discharged ; then water-dressing, early medicated to meet approaching
debility. .... A
The constitutional treatment is never thoroughly antiphlogistic. At
the commencement, evacuants are necessary ; for the stomach and
bowels an emetic and purgation ; for the liver, mercury, cautiously
administered ; the occasional alteratives, as perhaps the hydrargyrum
c creta. Early, tonics and stimuli are required—bark, wine, ammonia,
brandy, turpentine enemata, according to the features and exigencies
of the case. So long as the power of swallowing remains, the remedies
are to be perseveringly administered ; for, provided the suitable local
treatment has been practised, patients often rally successfully, even
thouo-h previously in extremis. Omit the use of the bistoury and potass
238
PRINCIPLES OF SURGERY.
—and all constitutional care, however skilful and unwearied, will not
arrest the tendency to collapse, or avert a fatal issue.
These strong expressions, in favour of strong remedies, are of course
applicable only to the more serious and urgent cases. There are many
examples of the disease, in which the SAvelling is but small, and
constitutional disorder proportionally slight; in these simple incision
suffices; in a day or two the slough is discharged, and granulation
advances favourably.
DIFFUSE CELLULAR INFILTRATION.
This resembles the phlegmonous erysipelas ; but the skin is not
originally involved. In the subcutaneous cellular tissue an asthenic
and rapidly destructive inflammatory action occurs; causing profu?e
secretion of thin, acrid pus, Avhich is extensively and diffusely infiltrated,
entailing the most ruinous consequences on the texture so affected.
The skin is undermined, or laid over a mass of slough soaked in puru-
lent secretion, ere yet it has itself begun to inflame. Sooner or later,
hoAvever, it does undergo that process; and this occurring, after losa
of both mechanical and vital support, soon overcomes its vitality; it
sloughs to a greater or less extent; and on detachment of the dead
portions, the gangrened mass beneath is disclosed. There is no limit-
ing fibrinous exudation, of a plastic kind ; the surrounding tissues aro
all open and defenceless, and may suffer by continued infiltration to an
almost indefinite extent.
Usually this affection is connected with the inoculation of a specific
virus, Avhich has the doubly unfavorable effect of raising vascular
action, Avhile vital poAver in both system and part—but especially in
the latter—is very much impaired. The bites of reptiles, stings of
insects, and punctures received during dissection, are familiar exam-
ples of such exciting causes. Or the evil matter may come from within
—not the less deleterious on that account; for example, urine infiltrated
into the cellular tissue is certain to light up an asthenic and rapidly
destructive inflammation there, Avith speedy extension of the mischief
by diffuse infiltration of the non-laudable inflammatory product; and
the skin usually sloughs early and extensively.
The symptoms of diffuse cellular infiltration, however caused, are
asthenic throughout. And never, even at the first, is there inflamma-
tory fever, as in the phlegmonous erysipelas—the disease which it most
closely resembles. There are pain, tenderness, a puffy diffused swell-
ing, heat, and sometimes a sense of throbbing; but Avith no apparent
affection of the skin at first, Avhich retains its normal hue, and may seem
even paler than the surrounding parts; very soon the SAvelling, in-
creasing fast, causing tension of the integument; and speedily thereafter,
the skin reddens, obviously inflames, and stands much in danger of
perishing by sloughing, ulceration, or both. When the surface has
given Avay, the discharge is profuse, thin, offensive, often bloody, and
ON PERIOSTITIS. 239
mingled more or less with the disintegrated cellular tissue. The con-
stitutional symptoms folloAV immediately on the first accession of the
local, and rapidly increase in severity ; they are those of constitutional
irritation, and tend strongly to the typhoid character.
Treatment.—The nature of the inflammatory action is such as to
afford no hope of its arrest before the suppurative crisis has been
attained. Leeches and punctures are of no avail; there is no time
suitable for their employment; the action almost at once reaches sup-
puration ; and herein again therefore the affection differs both from
erysipelas, and from the ordinary inflammatory process. A certain
amount of cellular tissue must be broken up and perish ; treatment can
only mitigate the mischief already done, and prevent its further exten-
sion. Incision is to be freely made, throughout the whole extent of
the infiltrated part; or if the infiltration be so situated as to render such
extensive cutting unsafe and inexpedient, at least let the wound be
free, early, and dependent. The infiltrating fluid escapes, tension is
relieved, a sufficient drain is left for the continued secretion, Avith space
and freedom enough for discharge of the parts already destroyed. The
subsequent local management, and the constitutional treatment through-
out, are to be conducted on precisely the same principles as in the
advanced cases of phlegmonous erysipelas, in Avhich similar injury has
accrued to both part and system.
CHAPTER VIII.
PERVERTED VASCULAR ACTION OCCURRING IN BONE.
To perverted vascular action occurring in the investing membrane
of bone, the term Periostitis is applied ; in the substance of the bone
itself, that of Ostitis. But be it understood that these terms are not
synonymous with true inflammation of the tissues affected, but include
the whole range of the inflammatory process, from its first and slightest
commencement, up to its highest and most destructive result. Accord-
ing to the issue, also, various names are applied;—plastic matter may
be effused, causing Node or hypertrophy of bone ; absorption may occur,
causing either general atrophy, or local loss of substance ; suppuration,
Abscess of bone ; ulceration, Ulcer ; ulceration of an intractable and
peculiar kind, Caries ; death of bone, Necrosis.
Periostitis.
This may be the result of direct external injury, as by wound or
blow; then its character is usually acute. Or it may originate from
240
PRINCIPLES OF SURGERV.
internal causes—and from none more frequently than from a vitiated
state of system induced by imprudent and unnecessary nicrcurialism;
then its progress is usually more staid and chronic. Or internal causes
may be combined Avith external, the former predisposing while the latter
excites—mercurialism may co-exist, for example, with exposure to un-
toAvard atmospheric influence ;—and then the progress and character of
the disease may partake of both the chronic and the acute. The pc-
riostitic patient is generally at, or above the middle period of life.
Fibrous tissue, such as periosteum, is not particularly prone to
assumption of the inflammatory process ; nor, Avhen assumed, does that
process tend to rapid and deleterious advancement, provided it be
limited to that tissue. How rarely, for example, does suppuration
occur in purely rheumatic affections, however acute ; and Ave have
repeatedly seen hoAV comparatively difficult it is for ulceration to s ize
on any fibrous investment. But the action, if at all cute or considerable,
is seldom limited to the tissue originally affected: both the subjacent
and the super-imposed become involved; the ordinary inflammatory
results proceed both above and beneath; and on these, in the latter
situation, the unyielding nature of the fibrinous tissue reacts most un-
favourably, causing much aggravation.
Periostitis, Avhether chronic or acute, is from the first attended with
great pain, on account of the unyielding nature of the tissue affected.
When, hoAvever, in the acute form, the action has reached the subjacent
bone and the intervening cellular connexions—as very early happens—
then the pain becomes excruciating; for the inflammatory process is
more active in the textures secondarily involved; tendency to effusion
is much increased, and this, being counteracted on either aspect by
periosteum and bone, sadly aggravates pain, and at the same time hurries
on the higher and more destructive results of inflammatory action.
Along with the pain, there is great intolerance of pressure, the lightest
touch adding much to the suffering. Swelling is not great; but from
the first tense, and very perceptible to both sight and touch, especially
to the latter. At first the skin is pale, lax, and uninvolved in the pain-
ful SAvelling beneath ; sooner or later, hoAvever, the swelling becomes
more diffuse and general, and the integument grows tense, red, and
tender. All the symptoms, but more especially the pain, undergo noc-
turnal exacerbation—as happens in most affections of the hard textures
—and the aggravation is not least distinct in those cases which are
most chronic in their nature. Day is the period of waste ; night, that
of repair. The inflammatory process, in its lower grades especially,
may be considered as analogous to the latter action—nutrition is an
exalted and perverted form ; its nocturnal exacerbation therefore may
be regarded as but an obedience of a general law. It is probable that
the inflammatory process, Avherever situated, undergoes this change;
but the occurrence is naturally most marked in the affections of unyield-
ing textures,_Avhere decided increase of turgescence and effusion'must
be accompanied by corresponding aggravation of pain.
Periostitis is invariably accompanied by important constitutional
symptoms. If the affection be acute, there is much inflammatory fever.
If slow and chronic, there is palpable derangement of the health of a
ON PERIOSTITIS.
241
corresponding type ; the patient grows pale, weak and thin ; loses his
strength, spirits, and appetite ; sleep is broken or altogether dispelled
by the nocturnal exacerbations ; constitutional irritation is plainly
developed ; it assumes the hectic type, and may advance to most
formidable severity.
The membrane is found changed; thickened, and increased in vas-
cularity ; softened in the acute form, dense in the chronic. Effusion
takes place on both its aspects ; diffuse exteriorly, limited toAvards the
bone. In the latter situation, if the action proceed no higher than active
congestion, the fibrinous effusion, being more or less plastic, may become
organized. A distinct, firm, tender swelling results, termed node ; con-
sisting of plastic fibrin, undergoing organization, exuded partly from the
periosteum, partly from the corresponding surface of bone secondarily
involved; and, unless either absorption return in great activity, so as
to remove all excessive deposit, or true inflammation supervene to undo
organization, that process not only advances to completion, but the fibrin
makes transition to cartilage and thence to bone ; the swelling then,
becoming less painful, more defined, hard, and unyielding. In the
simply fibrinous state, the swelling is termed a recent or inflammatory
node ; Avhen ossified, chronic, or confirmed.
When the action is acute and has extended from periosteum to bone,
with effusion betAveen, inflammation and suppuration are more likely;
the liquor sanguinis is no longer plastic, but degenerates into the puru-
lent formation. And such formation, happening betAveen tAvo most un-
yielding textures, induces aggravation of all the symptoms. The natu-
ral progress of the acute abscess outwards is arrested by the non-ulcer-
ating fibrous investment; the cellular connexions between the periosteum
and bone are broken up, and the abscess extends laterally, notAvith-
standing the limiting fibrinous effusion—the bone becoming more and
more stripped of its membrane ; the bone itself, by the pressure of the
accumulating pus, becomes distintegrated by ulceration, at the point or
points most compressed; and further, bone, at once inflamed and de-
prived of its nutritive membrane, is not unlikely to sink under the com-
plication of evils and become necrosed.
In acute periostitis, such destructive results, by suppuration, may
follow in the course of a few days ; the system at first oppressed by
grave inflammatory fever, subsequently exhausted by hectic. In the
chronic form, weeks and months elapse, with but little change in the
symptoms, or apparent alteration in the structural results ; but with a
frame gradually yet plainly yielding before the continued irritation. In
the latter class of cases, the membrane is found much thickened, dense,
and increased in vascularity ; the bone corresponding is usually adhe-
rent, opened out in texture, and roughened by nodules of osseous
deposit.
Examples are not wanting of the Avhole skeleton having been involved
in periostitis. Such cases, Avhether chronic or acute, are obviously of a
most formidable character, and can hardly be expected to haATe other
than a fatal termination. But usually, the disease is limited to one
chain of bones, to one bone, or to a portion of one bone. The parts of
the skeleton most liable to be affected are those most exposed to external
21
242
PRINCIPLES OF SURGERY.
injury, whether by mechanical violence or atmospheric exposure; the
shin of the tibia, the ulna, the clavicle, the sternum, and the bones of
the cranium, especially the frontal. In all aggravated cases, mercury,
as has already been stated, is usually much to blame ; and the worst
cases are those Avhich occur in scrofulous patients, Avho have suffered
from both syphilis and its supposed specific. The triumvirate of mer-
cury, pox, and scrofula, is sadly inimical to health ; many and serious
diseases are liable to be induced ; and of these, aggravated periostitis
is one.
Treatment.—It is customary to state that action, healthy and morbid,
proceeds Avith comparative slowness in bone ; but such is dangerous
doctrine, and may lead to inert and injurious practice. It is surely no
tardiness of progress which in a few days, from simple inflammation of
the periosteum, brings abscess, ulcer, and necrosis—one, or other, or
all. In truth there is no disease calls more loudly for active and ener-
getic treatment than acute periostitis ; for by such treatment alone can
such disasters be avoided. At the very outset, leeches are to be ap-
plied in large numbers ; counted rather by dozens than units ; and in
the robust, young and previously healthy, general bleeding may also be
practised ; our object is to make a full and decided impression on both
part and system, so as to avert the disease while there is yet time to
save structure. The part is kept raised, relaxed, and rigidly at rest;
and hot fomentations are diligently applied. Other antiphlogistics are
not forgotten; starvation, antimony, purgatives. The action having
been thus subdued, its results usually disappear, gradually yet satisfac-
torily ; if not, discussion is to be expedited by counter-irritation, and
the internal administration of the iodide of potassium—making sure
however that the acute action is subdued, before such remedies are
adopted.
Sometimes the action seems to be partially arrested, yet does not de-
cline ; a tense and painful SAvelling remains, unabated, and on the con-
trary tending still to increase. It is plain that relief of tension would
be a most important indication in such circumstances. For a similar
state of matters, unconnected Avith bone, AYe Avould freely practise in-
cision ; tension Avould be at once relieved, action would speedily de-
cline ; the Avound would suppurate, and its margins perhaps slough,
but granulation and closure Avould speedily follow. Here, however,
similar procedure Avould be rash and untoAvard ; tension would doubtless
be relieved ; but Avith suppuration, which is inevitable, Avould certainly
come either ulceration or death of the bone—the very results which we
seek to aAroid. Direct incision therefore is plainly unwarrantable. But,
by inserting a fine bistoury, or tenotomy needle, at a little distance from
the tense part, passing it up over it cautiously beneath the integument,
then turning and pressing its edge so as to divide the tense membrane
Avholly to the desired extent, cautiously Avithdrawing the instrument, so
as to make a valvular, oblique, and subintegumental Avound, and finally
closing the single in tegumental puncture immediately with a portion of
the isinglass plaster—in fact by completing the wound so as effectually
to prevent introduction of atmospheric influence, and thereby obviating
the chief risk of suppuration—we may obtain diffusion of the swelling,
ON PERIOSTITIS.
243
relieve tension, and so facilitate both resolution of the action and dis-
cussion of its results. This manoeuvre, however, requires skill and cau-
tion in its performance, and even then is not wholly devoid of risk. It
is therefore not to be indiscriminately employed, but reserved for those
cases which otherwise prove obstinate, and in which aggravation and
suppuration seem imminent.
When matter has formed, acutely, beneath the periosteum, direct in-
cision cannot be too early had recourse to. The part is to be treated
as an ordinary acute abscess. By no other procedure can the mischief
threatened to the bone be either limited or averted. Abscess having
already formed, subintegumental wound is unnecessary ; further, it is
inexpedient, as insufficiently evacuating the pus. If the Avound be
early, simple ulceration only avill have taken place ; on evacuation of
the abscess, ulceration quickly subsides, its cause having been removed ;
reparative action commences, and advances harmoniously with granu-
lation ; hard and soft parts cicatrize simultaneously. If incision be de-
layed, the ulcer not only deepens and extends, but is apt to degenerate,
subsequently proving slow to heal; or necrosis may occur to a greater
or less extent. But it is plain that this practice, so obviously beneficial
in the case of acute abscess, is never to be employed, unless Avhen the
indication of such a state of matters are most distinct and satisfactory.
Only Avhen the tactus eruditus and other signs of suppuration convince
us, that pus is really in some quantity accumulating between the peri
osteum and bone, is direct incision at all advisable.
In chronic periostitis, we also begin Avith leeching; but in a gentler
form; not so much Avith the vieAv of arresting or resolving the action
thereby, as in order to pave the Avay for its more appropriate remedy of
counter-irritation. A feAv leeches suffice ; followed by fomem^a^qn,.;
accompanied by rest, attention to posture, and a careful diet. Blisters
then follow, in succession ; or perhaps varied occasionally with liniment
of croton oil; and accompanied by the internal administration of the
iodide of potassium, in full doses. By this medicine, rest, and counter-
irritation, the greater number of cases will be satisfactorily subdued.
Sometimes, on account of peculiar obstinacy, more potent counter-irri-
tation may be expedient; the hot iron may be applied cautiously over
the part. Should the iodide of potassium interfere much with the sto-
mach, or seem to have lost its effect by habitual use, it may be either
combined with or temporarily superseded by sarsaparilla. Occasionally
the pain continues severe, more especially at night, notwithstanding
perseverance in such treatment; in these circumstances it becomes ad-
visable to give mercury, even although the case be one in Avhieh pre-
vious mercurialism is held the cause of the very evil now contended
with. The bichloride is considered the preferable form of the remedy
in sueh cases ; given cautiously, in doses of a tivelfth or sixteenth of a
grain, thrice daily ; either simply in solution, or in pill with sarsaparilla
and guaiac ; its use to be discontinued, so soon as the symptoms have
satisfactorily given way. But, as a general rule, mercury iu any form
is never to be given in periostitis, more especially so as to produce a
constitutional effect, unless other and safer means have proved unavail-
244
PRINCIPLES OF SURGERY.
ins-. For that mineral Ave well know to be as likely to cause as to
cure.
Neuralgia of Periosteum.—This membrane is sometimes the seat of
neuralgic affection. It may folloAV amputation ; it sometimes results
from a comparatively trifling injury. The part affected is usually of no
great extent. The skin is free from redness and swelling, but very
sensitive ; there is no apparent change of structure in either periosteum
or bone ; but in the former texture severe pain is felt, varying and in-
termittent—in short presenting all the usual neuralgic characters. Rest,
endermoid application of nitrate of silver, and the internal administra-
tion of iron, bark, or some other of the many remedies held available
in neuralgy, constitute the treatment. This failing, benefit may be ob-
tained from the lodgement of a seton over the affected part.
Ostitis.
As already observed, periostitis cannot long exist, Avithout the cor-
responding portion of bone being more or less involved. But not
unfrequently the action commences in the latter texture. It may af-
fect only the external surface, or originate and exist chiefly in the
interior, or involve the entire thickness. Also, it may be either acute
or chronic.
Like periostitis, it may be the result of external injury, or atmospheric
exposure ; or, the cause being internal, it may be termed idiopathic. Or
the action may extend from the soft parts, involving both periosteum
and bone secondarily ; as is not unlikely to happen in many cases of
neglected phlegmonous erysipelas. And again, no predisposing cause
is found more frequent or certain in its operation than mercury—more
especially if this have been both profusely and unnecessarily admi-
nistered.
The result of the action may be suppuration, internal, external, or
general; ulceration, simple or carious ; local death, or necrosis. Or
the action not reaching true inflammation, and imperfectly resolving,
there may be simply change of structure.
I. Change of Structure.—At first the bone is softened; apparently
by absorption of part of the earthy matter, fibrinous effusion occupying
its place. At the same time, its texture becomes more open; its sur-
face presenting a porous appearance ; as if the meshes of diluted ves-
sels had pushed aside the softened parenchyma, to make freer space for
themselves in their canals and foramina. Then, by continuance of
deposit, and this being gradually transformed into an osseous character
by transitional organization, the bone increases in bulk ; yet, though
enlarged, remaining for some time unusually soft and open in texture.
But as the action becomes more chronic, and someAvhat subsides, or-
ganization and transition of the deposit advance more thoroughly, and
to enlargement are added both condensation and induration of texture;
earthy matter being now deposited in even more than the normal pro-
portion. _ In consequence of this excess of earthy matter, it is important
to bear in mind, that the bone is impaired in vital poAver ; and there-
ON ABSCESS OF BONE.
245
fore less likely to control a re-accession of the inflammatory process—
the liability to suppuration, ulceration, and necrosis, is increased.
When the original action has completely subsided, we are not to ex-
pect the same rapid and satisfactory disappearance of the structural
change as in similar affections of the soft parts ; yet the absorbents are
not idle ; the proeter-natural deposit diminishes more or less ; and, if
inflammatory relapse do not occur, after some time the enlargement and
condensation may be greatly removed, and normal texture nearly re-
stored—more especially if the natural resolutive effort be judiciously
seconded by appropriate treatment. Such resolution, however, can
only be hoped for after long time, and under any circumstances is sel-
dom if ever altogether complete.
The progress of the action is indicated by symptoms in the main
very similar to those of periostitis. The pain is equally, if not more
severe, and has also its marked nocturnal exacerbations; it is more
deeply seated, and not so much aggravated by pressure. The soft
parts are early and much involved, but, at first at least, in a minor
degree of action; in the deeper cellular tissue, exterior to the perios-
teum, and intermuscular, there is much fibrinous effusion, clogging the
muscles, impeding motion, and affording a firm, deep, inelastic SAvell-
ing ; in the superficial cellular tissue, serum accumulates, occasioning
more or less oedema. Usually the skin too becomes red, someAvht/
stretched, and glistening. The constitution sympathizes more or less,
according to its susceptibility, and the intensity and duration of the
action.
The treatment is as for periostitis ; actively antiphlogistic in the out-
set, in order, if possible, to arrest the progress at once ; failing in this,
then counter-irritant locally, alternative constitutionally ; but at all times
let us be ready to cease from counter-irritation, and resume antiphlo-
gistics, should re-accession of acute action threaten to supervene.
II. Suppuration of Bone, (a.) External Abscess. 1. Acute.—We
have already seen that in acute periostitis, the subjacent bone is early
involved in similar action, that effusion takes place between, and that
if the inflammatory crisis be reached, abscess there is inevitable. _ For
such suppuration it is plainly immaterial whether the action originate
in the bone or in the periosteum ; it soon extends by contiguity to.
both. The pain is excruciating, distinct rigors usually accompany the
act of suppuration, the swelling is considerable and increasing, and
ultimately fluctuation may be discerned ; at an early period the integu-
ment reddens and becomes painful, and the subjacent cellular tissue is
infiltrated by serum. The nature of the progress of such abscess has
already been considered, as also the treatment which is suitable. By
early and direct incision only can mischief be arrested and repair satis-
factorily obtained ; the matter is discharged, ulceration of bone ceases ;
and so soon as the inflammatory action has sufficiently subsided from
its crisis, granulation begins from both hard and soft parts, and ad-
vances towards cicatrization. If incision be omitted, the matter accu-
mulates ; tension increases, so does pain, and then comes aggravation
of the original action ; periosteum is separated from the bone by lateral
extension of the abscess, more and more weakening vital power in the
21*
24(3
PRINCIPLES OF SURGERY.
denuded part; this, compressed by the pus, already inflamed, and with
its poAver of controlling action much impaired, readily yields before
that pressure ; it ulcerates, or may even perish in part by necrosis;
and Avhen the external opening and discharge of pus arc at length
effected, a large suppurated cavity, with ulcer of bone, necrosis, or
both, must inevitably complicate the case very unfavourably, and must
delay the cure—a complication and delay which it is in our power to
avoid by early incision.
2. Chronic.—But the action may be altogether chronic and limited,
and yet have reached to suppuration ; and the abscess may be small,
and chronic too—enlarging sloAvly if at all. In such a case we must
be more chary of the knife's use. The bone's surface has been so
gradually and gently subjected to pressure, that no ulceration has as
yet occurred ; Avere a direct incision to be made, this must inevitably
bring a certain amount of acute action as its direct result; and under
this acute inflammatory accession, ulceration or even partial death
might be induced. Such risk therefore is not to be incurred. The
practice, under such circumstances, is to attempt discussion by the
means formerly detailed as suitable for absorption of minute chronic
abscesses; the matter is gradually taken back into system, so gradually
as not to affect that injuriously ; the cavity proportionally contracts; and
the bone recovers its normal state without having ever sustained solu-
tion of its continuity, or been even threatened with exfoliation. Fail-
ing in discussion, or should from any cause the chronic abscess become
acute, then direct, free, and early incision is to be practised unhesi-
tatingly, as undoubtedly the less of two evils. Superficial abscess of
bone, Avhen large, is seldom chronic; but, if such should occur, the
same treatment is advisable as for chronic abscess in general; namely,
subcutaneous evacuation by a valvular aperture, carefully excluding
atmospheric air.
(5.) Acute Internal Abscess.—This may be either diffuse or limited.
1. Diffuse.—Inflammation has reached the suppurative crisis in the
lining membrane of the interior of the bone, and in the vascular meshes
of connexion betAveen that and the periosteum ; and there is no fibrinous
accompaniment, of limiting capability. The pus so soon as formed is
infiltrated into the cancellated texture, which—like cellular tissue of soft
parts similarly situated—gives way and is broken up, partly by ulcera-
tion, partly by more continuous local death. Partly by such destruc-
tion of texture, from within outAvards, partly by the passage of pus
outwards through vascular foramina and canals, partly by extension of
the suppurative action from within to the exterior, matter is sooner or
later found beneath the periosteum, and ultimately also in the more
superficial soft textures; but, as can be readily imagined, not till after
some time, much agony, great swelling, and serious constitutional dis-
turbance. The fate of the bone under such circumstances is inevitably
untoward ; it must fall a prey to either ulcer or necrosis, or to both, and
that extensively.
The treatment is to make a free direct incision, so soon as the pre-
sence of matter can be ascertained ; the pus and disintegrated debris of
the cancellated tissue are discharged ; farther extension of the mischief is
ON ABSCESS OF BONE.
247
probably prevented ; and an opportunity is obtained, favorable for ex-
trusion of dead parts, and for otherwise remedying the disaster already
sustained. Constitutional antiphlogistics are at the same time em-
ployed, proportioned to the symptoms; if progress towards cure be
slow, discharge copious, and natural power of system weak, hectic is
not improbable, and the general remedies must change accordingly.
2. Limited Internal Abscess.—The occurrence of this is more rare.
The cancellated texture of the heads of the long bones—more especially
of the tibia—is the ordinary site; the patient is at or beyond the
middle age, and generally has been much exposed to inclemency of
weather, particularly during night. The abscess is minute, the suppu-
rated part seldom exceeding the space of a shilling in extent; and it is
surrounded and limited by fibrinous effusion, which has not only been
perfectly organized, but made full transition into the osseous state. On
making a section of the part, the suppurated space is seen bounded by
dense recently deposited bone ; and this is usually lined by a distinct
pyogenic membrane. The texture around becomes affected by ostitis,
of a minor grade, causing gradual enlargement and ultimate consolida-
tion of the Avhole bone at that part. The primary action is also, no
doubt, of a low grade, and as such continues for some time, attended
by exudation of a plastic character, which becomes both organized and
transformed ; but in the centre of the so-inflaming part, as is usually the
case, the rise in action occurs ; the suppurative crisis is reached there;
and the matter, Avhen secreted, is limited and confined by the con-
densed bone just formed—Avhich barrier serves both a good and an
injurious end. It is plainly analogous to the limiting fibrinous exuda-
tion in abscess of the soft parts, but is not alike salutary; for whilst it
protects the surrounding parts from purulent infiltration and consequent
disruption, it also prevents, from its density of nature, any thing like
accommodating expansion before the accumulating pus, increasing
greatly the pain and constitutional affection, and tending to aggrava-
tion of the original disorder. Unless relief be afforded, a more formid-
able inflammation will be induced throughout the whole affected part,
inducing ulceration and necrosis, more or less destructive, with pro-
portional aggravation of the constitutional disorder.
Sometimes the suppurative crisis is not preceded by a persistent
minor grade of action, and in such cases there is little surrounding'con-
densation—indeed such barrier may be scarcely appreciable. Tendency
to diffusion is consequently great; rendering the progress of the case
less protracted, but not less destructive.
The symptoms of this affection are very marked. Excruciating pain,
constant, and rather on the increase than otherwise, is felt on one fixed
spot, of limited extent; usually on the front of the head of the tibia.
At that point the skin is red, but not tense, and only slightly swoln, if
at all. Some increase of the pain results from firm pressure ; but such
increase is infinitely below Avhat would accrue from direct compression
of the part primarily inflamed. The superficial bone and soft parts
have become involved in a minor grade of action, and it is from com-
pression of these that aggravation of the pain occurs. _ As usual noc-
turnal exacerbation is also present. A sensation of weight and throb-
248
PRINCIPLES OF SURGERY.
bing as well as of great pain, is felt and complained of by the patient
in the centre of the bone ; and to that spot, on Avhich he can lay his
finder, all his affliction is by him unhesitatingly attributed. No ordi-
nary antiphlogistic treatment, hoAvever active, affords relief. Consti-
tutional disturbance is severe, and of the inflammatory type ; sleep is
wholly denied, and not unfrequently delirium occurs. By continuance,
the poAvers of the system are gradually exhausted; the fever conse-
quently changes to the hectic typo ; and this may prove so urgent as to
demand amputation. More than one mutilation has been performed
above the knee, Avhich should never have happened ; perforation of the
head of the tibia, and evacuation of a small abscess there, Avould have
sufficed to resolve all the urgency.
It has been already observed, that usually, unless efficient relief be
afforded, aggravation and extension of the original action occur, in-
volving the Avhole bono at that part in suppuration, ulceration, and
death. Sometimes, hoAvever, the progress is more gradual; absorption
and ulceration occur in the parts surrounding the abscess ; this slowly
enlarges, and, obeying the general law, enlarges chiefly toAvards the
surface ; the surface is ultimately reached, the matter discharged, and
the bone relieved ; not unfrequently one or two small sequestra are dis-
charged along Avith the matter. But this is both a painful and pro-
tracted process ; occupying not days, butAveeks ; and ever liable to be
merged in general inflammation and death of the bone. Even supposing
that such accession do not occur, the constitutional disorder will be
inevitably great; life may be endangered, or saved only at the cost of
the limb.
Sometimes the abscess remains but little altered from its original
state, for several Aveeks ; seeming to have abandoned its acute charac-
ter shortly after its formation ; enlarging but little ; yet occasioning
continuance of symptoms of the most aggravated character, both gene-
rally and locally. On opening such a cavity, its pyogenic membrane
is found unusually vascular and distinct.
The treatment is simple. Instead of the amputating knife and saw, at
an advanced period of the case, Ave employ the scalpel and trephine at the
beginning. The ordinary means having failed to arrest the inflamma-
tory process, and the symptoms being sufficiently plain to convince us
that a limited internal abscess has formed, Ave make a free incision over
the marked spot, and there apply the crown of a trephine, perforating
toAvards the interior. On reaching the cancellated texture, pus will
probably begin to ooze by the side of the instrument; in withdrawing
the trephine along with the laminated portion of bone which it has
detached, a tea-spoonful or two of tolerably laudable pus escapes; and
then, evacuation having been fully accomplished, the patient passes
almost at once from the most cruel torments into placid repose. The
flaps are replaced, and the Avound treated on ordinary principles; all
inordinate action quickly subsides, and the part ultimately cicatrizes
firmly and permanently. Should the first trephining fail to detect the
abscess, and the symptoms yet be most convincing of its presence, the
instrument is to be reapplied, Avith hopes of a better success—as is well
exemplified in a case detailed in Liston's Elements, p. 116. By such
ON ABSCESS OF BONE.
249
comparatively simple procedure, both life and limb may be saved ; an
important fact, for which our profession stands indebted to Sir Benjamin
Brodie. The constitutional symptoms—invariably severe—are obviated
by the ordinary antiphlogistic means; but their best remedy, is by re-
moval of the cause—evacuation of the abscess.
(c.) Chronic Internal Abscess.—This may result from the acute ; ac-
tion subsiding, and pus continuing to be formed not more rapidly than the
surrounding parts can accommodate themselves thereto by expansion.
Or the inflammatory process is chronic throughout. The laminated
texture is gradually distended; the cancellated is either condensed,
assisting to form the parietes of the cavity, or is removed by absorption,
ulceration, or both ; sometimes small sequestra become detached, and
mingle Avith the fluid contents. The cavity steadily enlarges ; its con-
tents are purulent, but usually thin, commingled with the ulcerative
debris, and, as just obserAred, often containing small sequestra ; a dis-
tinct pyogenic membrane lines the interior ; and the Avails consist of the
expanded laminae of the bone, strengthened from time to time by recent
osseous deposit. On making a section of a bone so affected, its lami-
nated portion is sometimes found, notwithstanding much expansion,
considerably thicker and more dense than in the normal state. At one
point, hoAvever, attenuation of the parietes does take place, though very
slowly: and there ultimately discharge may be effected.
The symptoms are like the action, of a chronic nature throughout; a
dull indolent SAvelling forms gradually, with more or less affection of
the super-imposed soft parts, and irritation of the system.
The treatment consists of perforation of the parietes at the prominent
and thinnest part; the bistoury may be sufficient for this, alone, or the
assistance of a small trephine may be required. The purulent contents
are thus evacuated ; and an efficient draining of them is ensured, by
the establishment of a second and more dependent aperture, if necessary.
Granulation and repair advance in the interior; by uniform support
externally, from bandaging, centripetal contraction of the parietes is
favoured ; and thus, sloAvly, the cavity may fill up, the discharge cease,
the swelling in some measure subside, and both symmetry and usefulness
be at least partially restored. But not unfrequently, as can readily be
imagined, the progress toAvards cure is interrupted, the part threatening to
remain open, from failure of the reparative action. In such circumstances,
stimulation of the interior by injections, as of sulphate of zinc, is likely
to prove beneficial. And if these fail, a seton may be lodged tempo-
rarily, so as to arouse a fibrin-bringing action there, Avhich, on sub-
sidence of the true inflammation, may carry on repair with a renewed
and more successful energy. If the cavity be large, and its parietes
thin and superficial, the process of cure may be abbreviated by removal
of a part of these by incision, and then dressing the wound so as to ensure
contraction and filling up from the bottom.
There is an affection of bone termed Spina Ventosa, in some respects
resembling chronic internal abscess—by the ancients supposed to be of
a windy character, and hence, improperly, the term. Usually it is
classified with tumours of bone, and may be considered analogous^ to
the encysted tumour of soft parts. It consists of an equable expansion
250
PRINCIPLES OF SURGERY.
of the laminae, forming a cavity in the interior, occupied by a fluid, not
ahvays purulent; sometimes only puriform, sometimes clear and glairy.
The parietes, as the cavity sloAvly enlarges, are more and more attenu-
ated ; at some points they become only membranous, and ultimately
the membrane too may give Avay; no osseous deposit accompanies the
dilatation as in chronic abscess ; for the morbid process is from the
first independent of and unconnected Avith the inflammatory. The
cavity is lined by a membrane, more of a serous than of a pyogenic
character ; and sometimes membranous septa subdivided, as in the multi-
locular serous cysts. The distinctive characters of the SAvelling thus
are ;—contents not ahvays purulent; parietes simply expanded, and
consequently attenuated ; neither preceded nor accompanied by the
inflammatory process ; commencing, in the cancellated interior, by non-
inflammatory formation of a cyst, Avhich partakes largely of the serous
character. The treatment is similar to that of chronic abscess. Punc-
ture, satisfactory evacuation, external support, internal stimulation if
necessary. Partial ablation may sometimes be expedient, as in the
abscess ; and sometimes entire removal is no improper practice. For
example, the affection is not unfrequent in the phalanges of the fingers;
and if one of these be Avholly expanded into a large cyst, it is prudent
at once to amputate that phalanx, instead of attempting the protracted,
under such circumstances certainly imperfect, and probably abortive
cure by incision.
(o?.) Scrofulous, or Tubercular Abscess of Bone.-—This is of indolent
and chronic origin, liable to acute exacerbation. It is situated in the
cancellated texture ; in the bodies of the short bones, or in the articu-
lating extremities of the long. The first step is the deposit of tubercular
matter in the cancelli, either by perversion of simple nutrition, or ac-
companied by a Ioav grade of the inflammatory process. Such deposit
having accumulated in some quantity, asthenic inflammation supervenes,
spontaneously or by external injury ; the tubercular crumbles down, and
becomes mixed Avith a nondaudable purulent fluid. And this matter
may be either limited by an imperfect pyogenic membrane, or become
diffused by infiltration; most frequently, the abscess is of the diffuse
character. According to the site, either the general surface is ap
proached, and the tubercular debris, with pus, thence discharged; or
the neighbouring articular cavity is opened into, and by such irruption
grave inflammatory action is excited therein. But neither of these
events, it is plain, can occur, Avithout serious injury having been first
done to the cancellated tenure in Avhich the abscess originated.
The symptoms are, first, uneasiness and Aveight, rather than pain,
deeply seated in the bone ; increased somewhat by pressure, and con-
siderably by motion ; and occurring in a patient of an obviously stru-
mous habit. Enlargement of the bone then takes place at that part,
with increase of the uneasy sensations : the super-imposed soft parts be-
come oedematous, and the skin assumes a bluish colour. On occur-
rence of the suppurative crisis, enlargement becomes more rapid; pain
increases, but yet is comparatively dull; shivering takes place, and the
system thereafter sympathizes more or less. When the surface is ap-
proached, fluctuation and pointing may present themselves, unless in-
ON ABSCESS OF BONE.
2.51
cision he premised ; and, on opening taking place, the usual characters
of the scrofulous sore are exhibited, with the addition of a foul ulcer of
bone at the bottom of the cavity. When, on the other hand, an arti-
culation is opened into, violent aggravation of both local and constitu-
tional symptoms folloAvs, as will be afterwards described.
Treatment should be mainly prophylactic. By rest, fomentation, and
attention to the general health, it is our object to limit the tubercular
deposit and delay its suppuration. When this has occurred, we have
little or no power of controlling the untoAvard progress. All that we
can do, is to evacuate matter by incision, so soon as its presence has
been detected—seldom until it has appeared in some quantity in the
soft tissues—mitigating lneamvhile both local and general symptoms, as
they arise.
(e.) General Suppuration of Bone.—The abscess is neither external
nor internal, but diffuse, pervading the whole thickness of the bone, and
invariably acute ; the result of intense general ostitis. The bone, or
portion of bone, so affected, usually dies ; and may be said to be bathed
in a profuse secretion of pus, which not only burroAvs under the perios-
teum, but lodges also in the general soft parts, ultimately,-nay rapidly,
making its Avay to the surface ; in fact the case is one of acute necrosis.
The ordinary symptoms are, shivering; violent, deep-seated pain, con-
stant, and increasing; great SAvelling of the limb, obviously of inflam-
matory origin ; redness of the integument, as if erysipelatous ; consti-
tutional disorder, severe, and of the sthenic inflammatory type. ^ Mat-
ter forms and is discernible in the soft parts, deep, in contact with the
bone ; it approaches the surface at one or more points, and is discharged
by either an artificial or spontaneous aperture. Soon thereafter the
inflammatory fever may pass into hectic. The acute stage of abscess
has gone by; the chronic stage of necrosis has become established.
The treatment consists in active and early antiphlogistics, both gene-
ral and local, in order to prevent suppuration. When matter has
formed, early and free incision is required, not to prevent necrosis—for
that is impossible—but to limit its extent, and favour the natural pro-
cess of cure.
III. Absorption of bone.—This is more or less connected with
perverted vascular action, but altogether independent of true inflam-
mation.
1. Interstitial.—This may affect the Avhole of a bone, in conjunction
with deficient nutrition ; and the result is wasting or atrophy. Often
it may be termed an indirect and remote consequence of inflammation.
In what is ordinarily termed " white swelling" of the knee-joint, for
example, wasting of the bones of the limb, more especially of the
femur, is almost an invariable concomitant of the confinement to a se-
dentary or recumbent posture. This state of matters is to be obviated
by attention to the general health ; but, chiefly, by cure of the articular
disease, and consequent resumption of the wonted function of the limb.
A more important surgical affection is interstitial absorption, affecting
a part of a bone ; converting its dense laminated portion into a cancel-
lated texture, and ultimately imparting to its surface a worm-eaten ap-
pearance. This is a slow, insidious process, non-inflammatory; ob-
252
PRINCIPLES OF SURGERY.
scurely marked by dull uneasiness or aching in the part, cc.lennof the
super-imposed soft tissues, and lividity by passive congestion of the in-
tegument ; the part feels weak ; Avhen used, it becomes soon the seat
of pain as well as of fatigue, and at the same time the swelling is some*
what increased. In itself it is important as entailing change of struc-
ture, and impairment of function. But it derives its chief interest from
being the precursor of a much more formidable disease—caries. The
metacarpal bones are often so affected. The treatment consists of atten-
tion to the general health, rest, and counter-irritation; the last gentle,
but perseveringly maintained until the symptoms have satisfactorily dis-
appeared. And then a roborant and soothing plaster may be for some
time Avorn Avith advantage—as the emplastrum opiatum, spread on
thick leather.
2. Continuous.—This is the result of pressure, sufficient to stimulate
the absorbents to an increased, and probably perverted action, but not
intense enough to rouse the blood-vessels to assumption of inflamma-
tion. There is gradual loss of substance; and so a cavity may be
formed in the bone, even to a large extent, slowly, and almost Avithout
pain. After death, it may seem the result of ordinary ulceration; but
pathologically it differs Avidely from this ; there is no inflammation, no
formation of pus, no crumbling down and solution of the particles—in
short there is no true ulceration, nor any of the symptoms which ordi-
narily accompany and indicate this inflammatory product. For the
maintenance of such simple structural change, exclusion of atmospheric
influence is essential; admit this, and inflammation is the certain result
of the stimulus on the part, greatly predisposed to morbid action; pain
and rapid destruction of texture supervene, by ulceration ; and puru-
lent fluid is throAvn out in abundance.
Examples are afforded by gradual compression of bone from aneu-
rism, chronic abscess, or solid tumours—sloAvly enlarging. The affec-
tion may persist of its original simple nature ; more frequently it becomes
merged in the more rapid destruction by true ulceration ; for all that is
necessary to such supervention is external injury, and admission of
atmospheric influence, or sudden increase of the compression.
There is but one mode of treatment—removal of the cause, pressure;
by evacuation of the abscess, cure of the aneurism, excision or discus-
sion of the solid tumour.
IV. Ulceration of Bone.—This may be simple and tractable-
Ulcer ; or peculiar, and difficult of cure,—Caries.
1. The simple ulcer of bone, is the product of true inflammation, as
in the analogous condition of the soft tissues. Inflammation is inva-
riably its direct cause ; often pressure is the inducing, but more intensly
and suddenly applied than in the production of continuous absorption;
and although atmospheric influence is not essential, still it is very
favourable to the process. As a soft texture may inflame, suppurate,
and ulcerate, so may bone ; the inflammatory process originating in and
being mainly limited to the ulcerated part. Not unfrequently, how-
ever, the site of ulcer is not that which is primarily, but that which is
secondarily involved ; abscess, occurring either by ostitis, or by inflam-
mation of soft textures in the immediate vicinity of bone, compresses a
ON caries.
253
portion of bone not originally inflamed, and so induces its molecular
destruction. Such pressure may come from without or from Avithin ; the
abscess may have formed in the soft tissues, and cause ulceration in
the surface of the bone ; or suppurative ostitis having occurred in the
cancelled interior, and the pus making its way outwards by ulcerative
action, in obedience to the general law, a chasm in the bone neces-
sarily results.
The destructive process is simple, like its analogue in the soft tex-
tures. So long as pressure and inflammation continue, ulceration ad-
vances with more or less rapidity ; but on their removal, it also ceases,
and the process of repair succeeds. The healing process is not en-
tirely similar, hoAvever, as can readily be supposed. There is forma-
tion of new matter, as in the healing ulcer of the soft parts, and this
neAV matter is converted into bone, constituting Avhat may be termed
osseous granulations ; by these the surface of the healing sore is more
or less copiously studded ; but the supply of such new material is far
from being so abundant as in the cutaneous sore. The surrounding
bone, being an inelastic texture, does little toAvards diminution of the
chasm by centripetal movement; something hoAvever is affected by ab-
sorption. While the excavated surface is scantily throAving out neAV
osseous matter, interstitial absorption is advancing in the margins,
which are, as it Avere, bevelled off thereby ; and, ceasing to be abrupt,
slope gradually towards the central depression. Thus, partly from
elevation of the excavated surface by reparative action, partly from
levelling of the surrounding margins by absorption, the cavity comes
to be gradually diminished ; and the super-imposed soft parts, mean-
while busy in bringing themselves into a state suited to granulating
repair, now coalesce with the osseous granules beneath, and interweave
hard texture with soft, in a fibrous substance, Avhich, ultimately skin-
ning over, gives a firm, depressed, solid, Avhite, permanent cicatrix.
Sometimes the soft parts heal by themselves, independently of the
bone ; filming over Avhile the ulcer beneath is yet unclosed. The cica-
trix then is elevated, evidently unconnected with the bone, livid, soft
and painful; certain soon to be undone by re-accession of the inflam-
matory process, disclosing the ulcer beneath, perhaps wider and deeper
than before.
Ulcer of bone, though originally simple, and Avell disposed to heal,
may, from its extent, or by re-accession of inflammatory and ulcerative
action—and consequent vacillation in its progress—degenerate into a
weak or indolent condition, tardy and inefficient in re pair—as happens,
under similar circumstances, in the soft parts.
Treatment is conducted on principles precisely similar to those which
regulate that of the cutaneous sore. Rest, water-dressing, and anti-
phlogistic regimen—not forgetting removal of any obvious cause, at
the outset—during the inflammatory and ulcerative stages ; then water-
dressing, medicated so as to gently stimulate, external support by uni-
form bandaging, and maintenance of the vis vitae by suitable regimen,
not antiphlogistic, so as to ensure activity of repair.
2. Caries—This may follow on the simple sore ; more frequently it
is original. It is something more than a weak ulcer of bone ; it is
22
254
PRINCIPLES of surgery.
something less than a malignant or cancerous sore, as it is too often
designated. With many, there is a culpable laxity in the use of this
term, by applying it indiscriminately to all breathes of continuity of
bone of Avhatever kind. I shall endeavor to define the state of mat-
ters to which the term caries is truly applicable, and shall use that term
only to denote that condition; remembering the just saying of Mr.
Pott, how " clear and precise definitions of disease, and the application
of such names to them as are expressive of their true nature, arc of
more consequence than they are generally imagined to be. Untrue and
imperfect ones occasion false ideas, and false ideas are generally fol-
lowed by erroneous practice."
Caries is a breach of continuity in bone, of an altogether peculiar
kind, of itself almost incapable of cure, ytt not in any degree partaking
of truly malignant action. It is preceded and accompanied by inter-
stitial absorption, as formerly observed ; cancellated texture seeming to
be its proper nidus ; and degeneration of laminated bone into this state
seeming to be essential to its accession, in those parts where cancel-
lated texture does not naturally exist. The margins of the cavity con-
sequently have not the abrupt and firm character of the simple ulcer,
but are soft, spongy, and Avorm-eaten in appearance. The surface of
the cavity is sometimes of a uniform level; more frequently it is un-
equal, deep at one point, and comparatively shallow at another. It
has no adequate power of reparation ; it is either open and uncovered,
as if either inanimate, or yet undergoing disintegration—a probe pass-
ing crumblingly into it, as if into soft decayed Avoody fibre; or it ia
invested by tall, pale, fleshy granulations, which seem altogether
incapable of completing transition into bone. The ulcerative action is
rather chronic than acute; sometimes the bone is extensively and
rapidly destroyed ; more commonly, destruction is slow and gradual,
even Avhen great; not unfrequently but a slight extent of the hone's
surface is involved, even in cases of old standing. The whole of a
small bone, even the Avhole of a chain of small bones, or all the articu-
lating extremity of a long bone, may be attacked ; or a thin external
portion alone may suffer. A thin, foetid, purulent discharge, often
bloody, always acrid, usually more or less mixed Avith ulcerative debris,
and often containing small detached sequestra, exudes in considerable
t quantity; the corresponding soft parts are SA\oln by infiltration, and
broken up by suppuration, and one or more apertures exist in the in-
tegument, presenting the characters sometimes of the weak, sometime!!
of the scrofulous, sometimes of the irritable, sometimes of the inflamed
ulcer. A probe, passed through these apertures, reaches the bone, and
is found to sink into it; readily, Avith the application of little or no
pressure, if the surface be uncovered ; but not without pressure, if the
investing firm granulations exist, as very frequently is the case. In the
use of the probe, this must be borne in mind ; otherwise fallacy of
diagnosis is not unlikely to be incurred. Sometimes the probe may be
freely used, and little pain ensue ; but more frequently even its lightest
movement causes much suffering, and considerable hemorrhage of a
dark oozy nature ; both pain and bleeding being due to the soft parts,
ON CARIES. 255
rather than to the bone. Usually there is smart pain in the part, even
independently of external interference.
The diseased portion may be conveniently considered as consisting
of three parts ; the central, the ulcerous cavity ; a circle exterior to this,
affected by interstitial absorption; a third, beyond, consisting of com-
paratively sound bone, undergoing a Ioav grade of vascular action, of
the sthenic character. The two interior portions are incapable of effi-
cient re-production or repair ; the external is busy, in, as it were,
atoning for their deficiency, by the throwing out of new osseous matter,
sometimes in great abundance. Thus the carious cavity is surrounded
first by spongy Avorm-eaten bone, and more exteriorly by osseous spicula
or granules, forming a hard irregular ridge, sometimes but slight, at
other times extensive. It is not meant that such is the arrangement in
all cases, but only in the majority ; in some the ulcerous margin termi-
nates abruptly on the region of osseous repair. Sometimes necrosis is
engrafted on the ulcerative process ; and in the cavity may be found
dead portions, either of cancellated or laminated texture, partially
adherent, or altogether loose as sequestra.
The system invariably suffers to a greater or less extent; and the
disorder is of the asthenic type—constitutional irritation. Very often
the patient has been for some time manifestly cachectic, previous to
accession of the local mischief; if not, symptoms of a hectic character
are not long in supervening—all the more early and formidable if the
caries implicate an important articulation.
Caries may be simple, as just described ; or it may be of a scrofulous
or tubercular character. In the former case it is unattended by any
peculiar deposit. In the latter, it is both preceded and" accompanied
by deposit of tubercle in the open texture of the bone ; originating, in
fact, in the morbid condition formerly detailed as constituting the scro-
fulous abscess of bone. First there is the tubercular infiltration of open
texture, either originally cancellated, or rendered so by interstitial
absorption; then disintegration and suppuration of this; from the
ultimately open condition of the abscess, the state of ulcer necessarily
results, and the cavity of the uleer is more or less occupied with tuber-
cular masses of lardaceous character. The soft parts present the
usual appearances of the scrofulous sore ; and the system, both before
and during the progress of the local disease, shoAvs the ordinary signs
of the strumous cachexy, latterly aggravated by more or less of hectic ;
during the suppurative stage, irritative fever is not unlikely to be
present.
Causes.—As already stated, the disease may be primary ; or secon-
dary, an originally simple ulcer having so degenerated. Sometimes
the bone is not the texture first involved; infiltration and suppuration,
tubercular or not, may have occurred "in the soft textures, and thence
diseased action may have extended to the neighbouring bone ; or an
intractable ulcer of the soft parts, may come to implicate the subjacent
osseous structure,—as in lupus. By some, the affection of bone Avhich
follows on the truly malignant ulcer or tumour of soft parts is termed
caries, but unjustly ; it is a truly malignant or cancerous ulcer, just as
different from true caries as cancer is from the simply weak or irritable
256
PRINCIPLES OF SURGERY.
sore. In the tubercular caries, scrofula is of course to be considered
as the predisposing cause ; and slight external injury may serve for the
exciting. Svphilis may induce caries of the cranial and other bones;
the poison often seeming to enact the part of both predisposing and
exciting cause ; and the same may be said of mercury, perhaps with
greater truth—at least in those cases in Avhich that mineral has been
given both sakelessly and in profusion. An unfortunate conjunction
of the two poisons—mercurial and venereal—in a scrofulous system,ia
the parent of the Avorst, and not least frequent, forms of the disease.
Treatment.—Prevention is obviously the paramount indication. AVitli
this vieAv, if the symptoms of interstitial absorption be present, our at-
tention avill be directed to the arrest of this by rest, counter-irritation,
and constitutional care. If a simple abscess or ulcer occur on the sur-
face of bone, it will be our object to effect the healing of this as rapidly
as possible, in order to prevent degeneration. When merely ostitis is
present and demands our aid, Ave shall treat it actively yet Avarily; ac-
tively, in order to arrest the inflammatory process, ere yet the untoward
results of suppuration or ulceration have occurred ; Avarily, avoiding
exhaustion of the system, and still more the poisoning of it, by excess
of mercurial and other active antiphlogistics—a state favourable to the
occurrence of destruction of bone. And seeing that the local disorder
is usually so much connected with taint of the system, our attention
will be throughout directed toAvards the constitutional care, in con-
nexion Avith both prevention and cure.
When caries has occurred, the indications of local treatment are
abundantly simple. We are to take away the tAvo portions which are
incapable of repair—the interstitially absorbed, as well as the truly
ulcerous—and leave a solid foundation of normal texture, not only
capable of, but already engaged in, the business of efficient restoration.
Afterwards the part is to be treated as a simple ulcer; our anxious care
being directed to speedy, yet efficient and certain closure, lest renewed
degeneration supervene ; not resting satisfied with a blue elevated, soft
and spongy cicatrix ; but insisting on the establishment of one which is
firm, Avhite, depressed—plainly incorporated with the bone. For effect-
ing the removal, cutting instruments are infinitely preferable to escha-
rotics, in all situations Avhere excision is practicable. But as a general
rule, no operation of any kind should be performed on the bone, unless
the adjacent and super-imposed soft parts are in a quiet state. They
may be undergoing the acute inflammatory process ; they may be the
seat of acute suppuration, of acute ulceration, or both; and removal
of a portion of bone imbedded in such soft parts is almost certain not
only to prove futile as a means of cure, but actually to aggravate and
extend disease. The then carious portion of bone may be taken away,
but ulceration, instead of reparation, is certain to ensue, and by rapid
degeneration the carious condition is reneAved ; or a more intense and
general ostitis is kindled, and the partial caries is merged in general
necrosis. ^ And even supposing none of these untoward events to occur,
still the time of operation Avere inexpedient, as causing an unnecessary
and therefore an unwarrantable amount of pain.
The soft parts being already quiet, or having become so under suit-
ON CARIES.
257
able treatment, free incision is made through them, so as effectually to
expose the diseased portion of bone—previously tolerably well explored
by a judicious use of the probe. The extent of the doomed parts having
been satisfactorily ascertained, their thorough removal is then to be
accomplished by the saiv, trephine, bone-pliers, or gouge, as circum-
stances may render expedient. The articulating extremity of a long
bone, for example, may be readily taken away by the common saw, or
by a smaller straight-edged instrument. In a flat bone, such as the
cranium or scapula, the trephine may be more convenient. And in
many situations, Avhen either the previously mentioned instruments are
inapplicable, or when by them Ave have already taken away much but
cannot remove all, our object may be gained by an instrument closely
resembling the carpenter's gouge ; firm, ivell tempered, and of a sharp
edge ; used lightly, so as not to crush but cut; and yet used deter-
minedly, so as to ensure ablation of all the texture prone to reneAval of
ulceration and incapable of repair.
Escharotics in some cases are employed ; as for example, when the
patient resolutely objects to any other mode of removal; or when cut-
ting instruments have been used, and yet a border of suspicious charac-
ter remains; the extinction of such a suspected part may sometimes be
conveniently enough intrusted to cauterization. The actual cautery
may be applied; but unwisely. It effects too much. The carious part
is at once and satisfactorily killed ; but, as in all severe burns, the
texture immediately surrounding the eschar, though escaping with life,
has its vitality very much impaiied, and is more prone to disintegration
than repair. The potential cautery is infinitely preferable ; it destroys
the diseased part, just as effectually, though perhaps with less rapidity;
and at the same time the immediately adjoining parts do not in anyAvise
suffer, but at once institute a healthful line of demarcation for removal of
the dead part, and are well able to commence at the same time a sthenic
process of reparation. The preferable forms of potential escharotic are
the red precipitate of mercury in poAvder, and the chloride of zinc made
into a paste ; the latter is the more generally useful. Application is
made with intensity deemed sufficient to ensure death of all the sus-
pected part; the escharotic is then removed ; the AA'hole Avound is filled
gently with lint; and such dressing is continued, covered perhaps by a
poultice to mitigate vascular action, until separation of the eschar has
occurred ; the bone's surface is then treated as a simple ulcer, with two
paramount objects in vieAv—speedy healing of the sore so as to obviate
degeneration, and a healing from the bottom, so as to ensure the attain-
ment of a permanent and healthy cicatrix.
Certain parts of the skeleton are liable to caries, and not accessible
to either knife or caustics; as the knee and hip-joints, and the bodies
of the vertebra more especially. In these, the main reliance for cure
must be placed in Nature : the surgeon is qualified only to assist m the
procedure. But as, under such circumstances, ordinary indications of
cure cannot be carried out—or at least can only be slowly and imper-
fectly fulfilled—prognosis is unfavourable. It is still essential that the
carious surface shall be thrown off, and a healthy foundation for repair
obtained. This can only be accomplished by an effort of the part itself;
22*
2o8
PRINCIPLES OF SURGERY.
by ulceration, crumbling doAvn the carious and unnaturally cancellated
part, and leaving the surrounding normal texture unattacked ; ceasing
Avhen it comes there, its task having been accomplished, and giving
place to the reparative effort already there begun. Or the ulceration
may be accelerated, or at all events mixed up with a more continuous
death of the unprofitable part—necrosis. Such destructive process,
especially that by simple ulceration, may advance leisurely and quietly,
without any communication with the external atmosphere. One of two
events may then occur; the skin may continue unbroken, the purulent
matter becoming absorbed, as well as the molecular debris of the hone
which it then holds in solution ; and this, it is plain, can only happen
when the disease is of very limited extent, and the process altogether
chronic in its nature. Or the abscess, Avith its contained debris, and
perhaps sequestra, finds its way to the surface in the usual manner, and
is thence discharged. But it is in the early open condition that the
process is likely to advance most favourably; atmospheric influence
being favourable to acute—and consequently efficient—ulceration, while
at the same time a ready exit is obtained for the useless, and otherwise
fast accumulating discharge.
The auxiliary treatment, afforded by our art, in suspected disease of
these inaccessible parts, is, in the first place, to prevent the occurrence
of caries if possible, and obtain simple restoration to health; by atten-
tion to the general health, rest of the part, and counter-irritation.
When caries has doubtless begun, and the action is sIoav, as well as the
working of nature, watching over the general health, and maintaining
for the affected part a complete immunity from motion ; in the hope that
disintegration will prove but slight, and opening of the surface be un-
necessary, that the ulcer, freed from its carious surface, may either
simply cicatrize ; or, inosculating with an opposed part in like condition,
effect a compromised cure by anchylosis. When the diseased surface
is obviously large ; when in consequence the suppuration must be pro-
fuse, the destructive ulceration extensive and sustained—Ave cannot too
soon effect an aperture of communication vvith the exterior ; Avhich may
at once expedite ulceration, abridging the process of destruction, as
well as rendering it more likely to effect the object in view, and permit
free evacuation of the suppurative and ulcerative results. We keep
such a wound open and dependent; the vas3ular action which neces-
sarily follows on its infliction, we anxiously watch, and if necessary
subdue; and the powers of the general system are husbanded and
maintained.
It can be readily understood, however, that in but few cases a suc-
cessful issue is to be expected for this natural process of cure. Ulcera-
tion may extend, and the original carious surface so be destroyed ; but
most likely only to disclose a continuance of the carious state ; a sound
portion of bone, fit for repair, may be never reached; for, absorption,
changing structure, and impairing power, may prove still the precursor
of the ulceration. The system may be gradually Avorn out by the sup-
puration and its hectic. Or acute inflammatory action may seize on
the part; as is not unlikely to happen on the establishment of the aper-
ON NECROSIS.
259
hire for discharge ; irritative fever is lighted up in consequence, and
this may more rapidly exhaust the patient.
The foregoing points of practice, as to the surgically inaccessible sites
of caries, are obviously illustrated by reference to lumbar abscess, origi-
nating in caries of the vertebrae ; morbus coxarius ; and carious ulcera-
tion of the articulating surfaces composing the knee joint.
V. Death of Bone, or Necrosis.—This may be the immediate result
of external injury, the bone at once parting with its vitality; as in
extreme burns, in which all the component textures of the limb are
instantly converted into an inanimate eschar. Much more frequently
it is the indirect result of injury, the bone perishing by an overpower-
in"' inflammation. When unaccompanied by any other form of disease,
it is said to be simple ; compound, on the other hand, if combined with
caries, or attendant on fracture, as not unfrequently happens. When
consequent on the Avound or other external injury, it is called traumatic ;
idiopathic, Avhen originating without any appreciable exciting cause ;
often, in the young, a bone is acutely inflammed Avithout any apparent
reason, rapidly becomes the seat of suppuration, and dies to a greater
or less extent.
The extent of necrosis is very various. A mere leaf or scale of bone
may perish on the external surface; and this is termed Exfoliation.
A larger and considerable portion of the laminated texture may die ; or
this may retain its vitality, while the cancellated interior perishes ; the
dead portions, or sequestra, are called external and internal accordingly ;
and like terms are applied to the necrosis. Or the Avhole thickness of
the bone dies in one continuous mass, and the disease is then said to
be general. This general necrosis varies much in its extent; some-
times but a slight portion of a long bone so perishes and is thrown off,
sometimes several inches, sometimes nearly the Avhole. But it is sel-
dom that the entire bone suffers ; usually the articulating extremities
remain, the line of separation occurring there ; a fact Avhich has been
long recognised, and that gladly, by the surgeon, as compassing two
good ends ; first, the process of reproduction or repair is thereby facili-
tated ; second, the joints are saved from purulent irruption, and the
inflammatory destruction which Avould necessarily follow. While the
cancelled tissue of bone is prone to caries, necrosis is of more frequent
occurrence in the dense and compact portions of the skeleton.
The process of necrosis may be conveniently divided into stages.—1.
The bone, or portion of bone, inflames. Those cases in which the
bone is directly killed by external violence, Ave have already stated,
constitute the minority. In considering the process, therefore, it is
right that we should describe it as it most frequently occurs; and ac-
cordingly we begin Avith inflammation. This, as also before observed,
may be the result of external injury, as wound, bruise, or fracture ; or
it may be of apparently spontaneous origin. It may terminate in local
death, either in consequence of its own intensity, or on account of this
being associated with diminished poAver in the part affected. The as-
sociated cause is more frequent than the single, in the cases of traumatic
origin ; the injury not only kindling the ostitis, but at the same time
diminishing the vital power by which it is to be opposed. In wounds
260
PRINCIPLES OF SURGERY.
implicating bone, the periosteum is often removed ; this obviously im-
pairs power in the part so stripped, Avhich, accordingly, on the superven-
tion of ostitis, is predisposed to die. But it by no means follows that
because a portion of bone has been denuded of its periosteum, and that
even rudely, it must inevitably become necrosed ; acute ostitis occur-
ring, necrosis is imminent, but not inevitable ; the part may yet retain
a sufficiency of power for a successful struggle, and live. But if the
periosteum, and the membrane lining the interior—sometimes termed
endosteum—both perish or be removed at corresponding points, death
of the portion of bone so isolated, cut off from its vascular supplies, is
then indeed certain ; and but little, if any, ostitis is necessary to that
result.* When exposed bone retains its vitality, it is of a broAvn hue,
sounds dull on being struck, emits blood Avhen rudely handled, and is
covered by a self-secreted fluid ; on the contrary, if it be dead or dying,
its colour is white, it is resonant Avhen struck, it is dry, unless Avhen
moistened by purulent secretion from the surrounding parts, and does
not bleed when touched hoAvever rudely. Such signs it is useful to
remember, as not only auxiliary to diagnosis, but bearing strongly on
the mode of dressing. HoAvever it must also be Avell understood, that
a bone stripped of periosteum, at first may sIioav all the usual indica-
tions of retained vitality, and yet Avhiten and die ultimately ; and also
that an exposed portion of bone may become white, sonorous, and ap-
parently non-vascular, shortly after the infliction of the injury, and yet
recover Avith the thinnest possible exfoliation. In the latter class of
cases the process of reneAved and increased vascularization, in a part
previously exsanguine, may often be seen beautifully exemplified.
2. The bone dies. The changes just detailed, as indicating death
of bone, occur sometimes very rapidly, being completed in a few hours;
in other cases, the event may be protracted for several days, as if life
Avere gradually and reluctantly relinquished. If previously, during the
condition of simple ostitis, the periosteum Avere adherent, it is now
completely detached, and purulent secretion is interposed between it
and the bone.
3. The dead portion is separated from the living. The death, or
second stage, is often rapidly completed, and is never protracted.
This, the third, is invariably tedious and slow. The mode of detach-
ment is similar to that of sloughs of soft tissue ; but very different as to
the time employed ; a slough separates in a few clays ; but Aveeks and
months may elapse, and the detachment of the sequestrum may still be
incomplete. The extent of the necrosed portion is indicated by its
white, sonorous, insensible, and non-vascular characters ; and these it
retains throughout the Avhole process, seeming as if it were a macerated
portion of skeleton ; the only change likely to occur being a darkening
of its hue, by exposure to atmospheric influence, or to chemical action
from contact Avith the purulent secretion. But around this unchanging
* A marked sympathy of function hns been observed between the periosteum
and endosteum ; when the former has been destroyed, the corresponding portion of
the latter becomes peculiarly active, often causing an obliteration of the° medullary
canal at that point by a deposit of recent bone ; after injury to the endosteum simi-
lar sympathy is evinced by the periosteum ; in fact, destruction of either mem-
brane involves an increased duty and activity of production in that remaining
ON NECROSIS.
261
portion, and more especially in the parts immediately continuous with
it, there is great activity ; the colour is red or dark brown, evidently
from increased and increasing vascularity ; the slightest touch is both
painful and followed by blood, of a florid arterial hue ; a clear fibrinous
secretion is slowly exuding ; and the gentlest touch of the probe or
finger nail plainly indicates a softening of that part, by removal of a
large proportion of its earthy matter. In short, Avhile the dead part is
undergoing no change, unless perhaps a variation of hue, the living
parts all around are softened and increased in vascularity, busy in car-
rying on an inflammatory process of a truly sthenic kind. This quickly
terminates in suppuration and ulceration; and so a sulcus is begun,
Avhich, by gradually deepening, ultimately—but not till after a long
time—detaches the dead from the living, resolving the former into the
condition of a loose sequestrum. As in the similar process in soft parts,
ulceration does not proceed alone; reparation follows quickly on its
heel; and no sooner has the primitive sulcus been formed by the action
of destruction, than osseous granules begin to spread, by the action of
repair, from the margins Avhich the ulceration has only just left. Now,
the stage of separation commences immediately on the completion of
that of death ; and the former is not well begun, ere the Avork of lepro-
duction has laid its foundation. Therefore it may be said, so Avise and
provident is Nature, that the necrosed part is scarcely yet dead, ere
the formation of its substitute has been duly set in progress. The
separation, it has been stated, is invariably sIoav ; and it is Avell that it
is so; for, the formation of new bone, to supply the place of the old
Avhich has perished and must be throAvn away, is also a process inevi-
tably tedious, even although early begun; the two—separation of old
and reproduction of neAV—advance pari passu ; and it is surely a most
beneficial and Avise arrangement Avhich has decreed that the one shall
not be completed leaving the other much imperfect; that the portion of
old bone shall not be loosened and cast away as a useless thing, until
an efficient substitute has been prepared to occupy its place and func-
tion. During- the process of separation, or ulceration, there is neces-
sarily a constant, and often a profuse secretion of pus ; this is discharged
externally through apertures in the soft parts already existing; or it
burroAvs and accumulates at neAV points, Avhere free and dependent
incision soon comes to be demanded. The discbarge is usually thick,
and yellow—laudable in appearance—charged Avith more or less of the
ulcerated debris, and invariably possessed of an oppressive and pecu-
liar foetor—a sickening heavy odour, which, Avhen once felt, can ever
after be readily recognized—a sure sign of necrosis.
4. Separation of the dead portion is completed. The ulcerative action
has encompassed it on all sides and beneath ; it is noAV loose, unless
where hemmed in by exuberant formation of new osseous matter above
and around, as is not unfrequently the case—a redundancy of reparative
effort by no means to be complained of, being obviously by much the
safer side on which Nature may err—and is to all intents and purposes
a foreign substance ; detached from the living; of no farther use, and
no longer recognised as a part of the living economy ; on the contrary,
a noxious body whose presence is resented by continual suppuration
262
PRINCIPLES OF SURGERY.
and excitement in the living parts, and Avhich cannot then be too soon
extruded from the system.
5. The dead portion is extruded. As in the case of threatened lodge-
ment of any other foreign substance, suppuration is the main agent in
this. By the pus, the loose sequestrum is, as it were, floated to t'ie
surface, and there exposed. And if Surgery be either slothful or alto-
gether in abeyance, Nature may even complete the task of final dis-
cbarge, though sloAvly and painfully and with much exhaustion to the
general frame. But another agent is also at Avork. By the ancients it
was supposed that the dead portion Avas simply pushed off by granulation
from beneath, ere yet it Avas detached from its continuity with the liviiv
texture. Such Ave have seen is not the case. It is separated by a very op
posite process ; not formation of iicav matter, but disintegration of the
old. But to this disintegration of the old, as a means of separation,
formation of neAV as a means of repair almost immediately succeeds.
This reparative action is not limited to the margins and surface of the
sulcus, but folloAvs the ulceration throughout its Avhole track; so that
Avhen the dead part is completely detached and loose, it is virtually
borne on a bed of granulation, which, continuing to spread upAvards in
the reproductive effort, obviously assists in carrying outwards the se-
questrum and favouring its approach to the surface. At the same time,
be it ever remembered, this and every other effort toAvards expulsion
may be fully counteracted by retention of the dead and detached part,
in consequence of a tight embrace of the living substitute Avhich has
formed over and partially incased it.
6. Reparation is completed. This Ave have already seen begins at
the same time as the process of separation, and is originated by the old
bone at the living margin of the ulcerative sulcus. From this point it
advances, consentaneously Avith the process of separation, in two parts,
a deep and superficial; the former, following close in the track of the
ulceration, consists of osseous production from the living bone beneath
the loosening sequestrum ; the other, begun by bone, but apparently
carried on by periosteum, invests the dead part on its exterior; gradu-
ally shelving over and incrasting it, as bark does a tree, and hence
often termed the cortical portion of the substitute, or neAV formation.
Wherever the periosteum is entire, there the formation of this cortical
bone proceeds, continuously Avith that Avhich has come in gradual ex-
tension from the parent shaft. But in several places it is probable that
periosteum is deficient. So soon as the part died, its periosteum, as
formerly stated, became detached from it, and pus was interposed.
This pus must sooner or later find its way to the surface ; and for this
purpose solution of continuity is made in the investing membrane either
by the knife or by ulceration, more frequently by the latter. Such
apertures remain open, not unfrequently Aviden, and through them the
pus continues to be discharged. The cortical formation, begun by
bone, and apparently maintained—nay, chiefly effected—by periosteum,
having reached such an aperture, has its continuity interrupted ; Avhere
the membrane is deficient, so is the osseous shell; it passes round the
margins, and an aperture is formed in the neAvly constructed case of
bone corresponding to the opening in the periosteum. In fracture,
ON NECROSIS. 263
without suppuration, ossification Ave shall find begun by bone, continued
by periosteum, and Avhere that is deficient sustained by the surrounding
parts Avhich assume periosteal character and function ; and consequently
the incasement of bone under such circumstances is continuous. But
there is no substitute for deficient periosteum; the surrounding soft
parts have suppurated, and are themselves reduced to the condition of
an aperture or canal for discharge of matter. This, hoAvever, is not a
disadvantage ; on the contrary, Avere the deficiencies of periosteum in-
variably supplied by adventitious structure of similar capabilities, the
cortical formation would also invariably be continuous; the purulent
matter would be denied an outlet, and all the pains and dangers of
acutely accumulating and deeply seated pus Avould inevitably ensue.
As it is, the deficiency of periosteum is not supplied ; the cortical for-
mation is at that point proportionally defective ; and a permanent aper-
ture, termed cloaca, results; communicating with the cavity which
contains the sequestrum, on the internal aspect, with the suppurated
aperture and canal of the soft parts exteriorly, and of the greatest use
in securing efficient discharge of the purulent or other fluids. The ex-
ternal orifice of this discharging canal is usually callous, and of an ele-
vated or pouting character; it is termed & papilla, and in every case
where necrosis is at all extens'iAre, there are not one but several such
purulent canals, through the cloaca in connexion with Avhich a probe
maybe made to impinge on the sequestrum. Through these apertures
the condition of the dead portion may be from time to time ascertained ;
and so soon as it has become loose, it is through these apertures, en-
larged if need be, that it is removed. So soon as it has been discharged,
the two portions of the neAV osseous formation tend to coalesce, and so
complete the construction of the dead bone's substitute. Hitherto, the
sequestrum, as a foreign substance, Avas interposed between ; noAV, the
cortical frame, descending, comes ultimately to mingle the soft osseous
granules of its internal aspect with those which are rising from the
subjacent stratum of original bone. And so, someAvhat as in chasm of
the soft parts, the cavity previously occupied by the sequestrum, comes
ultimately to be filled up, partly by the continued formation of new
matter, partly by the mutual approach of the parts already formed.
Suppuration ceases gradually ; the cloacae, no longer useful, are sloivly
filled up—or at least diminished—by new formation from the osseous
margins; the whole part becomes firmly consolidated ; and the inflam-
matory process altogether subsides. Before removal of the dead part,
there was much bulky swelling of the limb, partly from the infiltrated
condition of the soft parts, partly from the elevated position of the cor-
tical bone. But now this seeks a lower level; besides, the _ absorbents
so act as to condense and strengthen the new texture, rendering it more
efficient as part of a column of support; and at the same time, the in-
flammatory process having in all its parts and every where abated,
absorption is not idle in the super-imposed soft texture. _ In conse-
quence, the unseemly swelling gradually disappears ; and ultimately the
part has both its function and its. symmetry more or less completely
restorer!
An analogy plainly exists between reproduction of bone, and repara-
264
PRINCIPLES OF SURGERY.
tion of loss of substance in the soft parts. The granulations which fill
up the latter chasm, and, restoring all to one level, permit the forma-
tion of neAV integument, are analogous to the ucav osseous production
from the parent bone ; the cuticular investment, gradually extending
from the circumference, to effect cicatrization, has for its analogue the
cortical formation beneath the periosteum ; Avhich, covering in the deep
substitute, may be said to effect its cicatrix.
Hitherto Ave have been speaking of the restorative process as occur-
ring in a case of partial necrosis; an external portion only bavin"
perished ; having living bone on one side, and periosteum on the other.
Events are very similar in the other forms. When the necrosis is in-
ternal, a part of the cancellated texture only having died, reparation
follows rapidly on extrusion of the sequestrum through an aperture,
formed by ulceration, in the laminated portion—which opening is, like
the corresponding interruption of continuity in the cortical portion,
termed a cloaca—and is effected entirely by the surrounding living
bone, Avhich constituted the parietes of the cavity in which the seques-
trum lodged. At first the new structure is of preternatural density; but
by continued action of the absorbents, continuity of normal texture is
ultimately re-established. When the internal sequestrum is small, the
original inflammatory action having been but limited, and the present
suppuration being but slow and slight, perforation of the bone for dis-
charge of both pus and sequestrum may be a very tedious process ; mean-
Avhile, by the continued presence of the foreign body within, an ostitis
of a minor grade is permanently maintained in the vicinity, and perhaps
to a Avide extent; in consequence, the bone may become much en-
larged, as Avell as condensed in its structure, and often is roughly nodu-
lated on the exterior. A someAvhat similar change of the shaft of a
long bone follows on the formation and lodgement of a large internal
sequestrum, in connexion with which a cloaca may have been early
formed, but too minute to admit of spontaneous extrusion.
When a portion of bone including its Avhole thickness ha3 perished,
the process of separation advances in the usual Avay; as also the com-
mencement of reparation by osseous production from the living margins
of the sulcus. The osseous production, begun by the bone, is continued
by the periosteum, gradually shelving over the Avhole exterior of the
dead portion. The sequestrum, when loose, is dislodged—perhaps by
the osseous granulations around—from its rectilinear relation to the
living shaft; it then gradually seeks the surface ; and thus both room
and opportunity are afforded for the parent bone, on each mutilated
aspect, to send forth its reproductive formation. After extrusion of the
sequestrum, the cortical portion falls imvards, as usual, and coalescing
with Avhat is being formed by the old bone, a solid and efficient substi-
tute is ultimately obtained. Still the restoration of the bone's conti-
nuity is due to both bone and periosteum ; still the former texture takes
the initiative in the process ; and the two formations, from periosteum
and bone, must advance together, in harmonious co-operation. Com-
plete reproduction, hoAvever, is not to be expected in all cases. If a
small portion only of the entire thickness perish—say half an inch, or
an inch—doubtless it will be ultimately though slowly reproduced ; the
ON NECROSIS.
265
parts are equal to the task required of them ; the hone, more especially,
is quite able to duly overtake its part of the duty, the osseous formation
from either end uniting to form a dense and compact reunion of the
central portions of the shaft. In all cases the periosteum, when left
entire, is capable of executing its share, namely, the formation of the
cortical portion ; but that is not enough ; the cortical portion, if left to
itself, after extrusion of the sequestrum, unsupported by an interior pro-
duction from the bone, shrivels and bends, is altogether insufficient as
a column of support, and ultimately comes to be in a great measure
removed by absorption. Noav, reproduction from the mutilated osseous
surfaces can only extend a certain length ; in the higher classes of ani-
mals, reproduction of tissues is not indefinite, but has its limits; the
two portions of bone will by reparation from either end meet efficiently,
by overtaking a distance of a feAv inches, readily. In seeking to tra-
verse a greater space, hoAvever, the reparative effort is likely to flag
and fail; the osseous nodules do not coalesce, but taper finely off, end-
ing in a point coherent Avith the condensed soft textures around. And
therefore practically it must be remembered ; that when a sequestrum
has come away, including almost the entire shaft of a long bone, repro-
duction can scarcely be expected to prove complete, and probably the
limb Avill ever after be more or less inefficient as an organ of support
and motion. It is astonishing, however, how successful the restorative
effort sometimes proves, even in circumstances of but little hope. In
not a feAv instances, long bones have been almost Avholly reproduced.
And therefore in necrosis of the entire thickness of the shaft, even of
great extent, the chances of cure in the ordinary way ought invariably
to be afforded. The short bones, however, if wholly necrosed, are never
reproduced.
Also, let it be borne in mind, that for suitable reproduction under
any circumstances it is essential that the true inflammatory action shall
subside; otherwise the fibrinous effusion will prove but sparingly plas-
tic, its major part degenerating into a purulent secretion. In practice,
our principal care is directed to Avarding off inflammatory re-accession;
knoAving well that should this occur, repair will be interrupted, the
cure be at least delayed, and perhaps rendered wholly abortive.
Such is necrosis. As already stated, it may be partial and external.
Then the sequestrum has its peculiar characters. For, the dead por-
tion having rapidly parted Avith vitality at a very early period of the
disorder, ere it had time to undergo change, it presents, on its removal,
the usual appearances of a portion of the external, dense, laminated
texture of bone ; as if it were a part of a macerated skeleton ; but rough
and irregular, at its lower and lateral aspects, Avhere by the ulcerative
process it has been sloAvly and unequally separated from the living tis-
sue. Or it may be partial and internal. Then the sequestrum is very
distinctive of its original site ; being not only loose as ordinary cancel-
lated texture, but also rough and scarbrous at every point, showing no
surface of a smooth and laminated character. Or the entire thickness
is included, presenting a portion of the bone, rough and irregular—
usually much spiculated—at either extremity; but in other respects
seeming as if artificially removed from the skeleton.
23
2G6
PRINCIPLES OF SURGERY.
Also, necrosis may be either chronic or acute. Or rather it may be
more accurately stated, that the ostitis which leads to the local (hath,
may be either chronic or acute. For the major part of necrosis, that is,
the separation of the dead portion of bone, and the formation of its gub-
stitute, is invariably chronic, occupying long time in completion, and
accompanied by but a very minor grade of the inflammatory process.
The bones most liable to suffer are those most exposed to atmo-
spheric influence, and mechanical violence; and the disease, more
especially in its acute form, is found to prevail more frequently in the
young than in the old. The causes of necrosis may be briefly stated
to be the same as those of its first stage—ostitis.
Symptoms.—The symptoms are at first those of acute ostitis; on sup-
puration having occurred, these are aggravated ; no relief following the
suppurative crisis, as sometimes happens in the soft textures, for here
the first investment of the pus is invariably dense and unyielding. But
relief comes with evacuation of the matter, Avhether effected by nature
or by art; by the former, the process is tedious, and the abatement of
Symptoms proportionally sIoav ; by the latter, if early and efficiently
adopted, relief is both instant and great. All the surrounding soft
parts are very much involved, from the beginning ; at first infiltrated
by a plastic effusion, consolidating as well as thickening and enlarging;
afterwards the seat of suppuration, more or less extensive, sometimes
diffuse, more frequently limited by the fibrinous condensation. The
matter is discharged usually through several apertures, the number
generally bearing a proportion to the extent of the disease ; the pouting
external orifice, as already stated is termed a papilla; the internal, the
result either of deficiency of the periosteum, or of perforation of the
old bone—according as the necrosis happens to be internal, or not—is
termed a cloaca. Through the canal, Avhich ultimately assumes quite
a fistulous character, the presence of the dead portion of bone is de-
tected, and its condition as to detachment may be from time to time
ascertained, by the use of the probe—or Avhat is better, by the intro-
duction of a finger, should the space permit. Should the sequestrum
be internal, it is felt rough, yet dense ; Avhen external, it is felt smooth
and solid, except at the circumference, Avhere by the sulcus of separa-
tion it has been rendered rough and irregular. During the stage of
separation, and the concomitant one of reparation, discharge is con-
tinued ; usually copious, and invariably foetid as before stated. In con-
sequence, the constitutional symptoms Avhich during the ostitis, both
simple and suppurative, had shoAvn all the characters of acute inflam-
matory fever, often intense, change now into the assumption of hectic.
But the local inflammatory process has not yet subsided ; so long as the
foreign body—as the sequestrum truly is—remains unextruded, its pre-
sence will continue to be resented by the living parts; true inflamma-
tion is sustained in its immediate vicinity, as essential toAvards the
ulcerative suppuration ; a minor grade of action continues to pervade
the whole part; the substitute bone is busily advancing; in the soft
parts, deposite is still in the ascendant, and the absorbents are doing
but little towards the remodelling of the limb. Besides, the soft parts
become increased in vascularity, sometimes to a very considerable de-
ON NECROSIS.
267
gree ; so that when incised—and they cut like a piece of gristle rather
than ordinary soft textures—hemorrhage is invariably profuse ; not only
because the vessels are both more active and more numerous, but also
in consequence of the natural hemostatics being opposed by the dense
structural change of the parenchyma. Should inflammatory re-acces-
sion occur, the symptoms will all be renewed with their pristine seve-
rity ; and if the neAvly-formed pus be so situated as not to find a ready
exit, it is most probable that serious extension of the original necrosis
may ensue. And thus it may happen that necrosis, originally limited
to but a small part of laminated texture, may ultimately involve, not
only the AA'hole thickness, but almost the Avhole extent of the bone.
When the sequestrum has become wholly detached from the living
bone, it does not always seem loose. For it may, at more than one
point, be bound by the tight embrace of the neAV cortical formation.
Generally, however, so soon as detachment is complete, the seques-
trum is more or less moveable, as the finger or probe will readily tes-
tify ; and if not artificially removed—as it should be—in due time it
makes its appearance at the surface, and projects there ; the protruded
portion "becoming blackened, apparently through atmospheric influence.
And, as a general rule, it may be safely held that a dead portion of
bone, which is protruding through an external opening in the soft parts,
has been completely loosened from its connexion with the living bone ;
and that if it seem fixed, it can only be on account of its retention by
the cortical portion of its substitute. Sometimes the substitute may
itself perish, by inflammatory accession ; a result not at all improbable
when Ave consider how recent and comparatively incomplete is its
structure, and consequently bow low its vital power of resistance or
control. And this affords another reason why such inflammatory re-
accession should be anxiously provided against, throughout the Avhole
period of repair. Should the super-imposed soft parts happen to
become the seat of the hospital sore, the substitute cannot fail to be
more or less exposed and involved, and may consequently die and
come away, in whole or in part.
When the sequestrum has not only become loose and been dislodged,
but also has been fairly removed, the inflammatory process gradually
subsides in all its parts. The cortical portion of the substitute con-
tracts, condenses, and sinks to meet the rising new structure which has
been elaborated by the parent bone, and which has been a means of
effecting the displacement and extrusion of the dead part. The two
portions having coalesced, deposit and absorption advance in harmony
within the mass, fashioning it into a goodly imitation of the part which
has been cast off, and restoring both symmetry and function to that por-
tion of the skeleton. At the same time—action gradually fading as it
recedes from the centre of operations—deposit ceases to be excessive
in the soft parts, the absorbents become actively engaged in removing,
as far as in them lies, the excess which has already occurred, and both
the induration and enlargement of the whole limb slowly subside ;
ultimately, the normal girth is approached, but is seldom if ever
actually attained ; pain and stiffness gradually diminish, and function
too is restored.
268
PRINCIPLES OF SURQERY.
The time occupied by the various changes is extremely various. In
acute external necrosis of a very limited extent, many days may not
elapse betAveen the first onset of the inflammation and the final extru-
sion of the sequestrum. In more extensive examples, by weeks we
will prove more ready reckoners of the time. When the whole thick-
ness of a bone has perished, to some considerable extent, many months
may be, and usually are, consumed, ere the bone has been got away;
and almost an equal term may be required, ere, subsequently to that
event, the limb resumes even an approach to its pristine form and
function. In the young and othenvise healthy, the progress will be
more rapid than in the aged and infirm ; and much will also depend
upon the treatment. If inflammatory re-accessions have been cither
directly induced, or not sufficiently provided against, the term of cure
may be protracted almost indefinitely. In spongy bones too, the pro-
cess is ordinarily more rapid than in dense; the former being more
vascular, and better capable of energetic effort. Also the bones of the
superior extremity have an advantage, in this respect, over those of the
loAver.
Treatment.—Again, prevention is to be considered paramount. Treat
the preliminary ostitis, Avith energy yet warily, in order that it may be
arrested in its progress, ere any destructive result has yet begun.
When suppuration has taken place, and the doomed portion or por-
tions of bone are dead or dying, our object is a minor one ; to mitigate
symptoms, prevent extension of evil already incurred, and favour the
advancement of repair. The first and not the least important indica-
tion to be fulfilled, is, early and efficient evacuation of the purulent
formation, which bathes the inflamed bone, and has detached it from
its periosteum. Some considerable time must be unprofitably con-
sumed, ere the pus can Avork out its OAvn discharge through the
periosteum and other unfavourable investing tissues; meanAvhile the
patient's sufferings will have been great, and aggravation of the original
evil not inconsiderable. Time, texture, and torture may be all saved
by an early, free, and direct incision ; Avhich, accordingly, should in-
variably be practised, so soon as the indications of suppuration are
sufficiently manifest. Detachment of the sequestrum we commit en-
tirely to Nature, contenting ourselves with overlooking her operation;
and taking especial care that she shall not be interrupted. With this
latter object in view, the part is kept quiet, used as little as possible,
and not put in the Avay of external violence ; and should inflammatory
re-accession at any time threaten, leeches, fomentation, especial rest,
and the general antiphlogistics if need be, are at once to be employed
with a view to its speedy arrest. On this account also, during the
chronic stage, when perhaps the purulent secretion is great, and hectic
either threatened or fully developed, and when consequently we are
anxious to support the system in its difficulties—that support must be
prudently conducted, and made to vary from time to time, as circum-
stances may demand, in order to avoid its being the cause of local
over-action.
When the sequestrum has become wholly detached from the living
bone, by completion of the ulcerative sulcus in the margin of the latter,
ON NECROSIS.
269
Nature's exclusive operation is over, and it is then our cue to interfere.
Nature's poAver of detachment is adequate and admirable, but her
power of extrusion is Aveak and imperfect; and the surgeon who
deliberately imposes on her the latter effort is both negligent and un-
skilful. She may, and often does, accomplish the task ; but only after
much suffering to the patient and exhaustion of his frame, and not until
much structural change, perhaps irremediable, has occurred in the part
—all unnecessary, and which by the judicious assistance of the sur-
geon, timeously afforded, should haAre been altogether preArented.
But perhaps a more common error in practical surgery is, interference
with the sequestrum before it has become loose. To lay hold of it
then, and use violence, after exposure by incision, is certainly to induce
a combination of evils. The evulsive effort fails; and consequently
the patient has been put to a grave amount of pain unnecessarily and
fruitlessly. By the violence, inflammatory re-accession is certainly
induced in and around the part originally implicated ; in other Avords,
a fresh ostitis, probably both acute and extensive, is induced, and
aggravation of the necrosis is most likely to follow. Also the loss of
blood which attends on such an attempt, whether successful or not, is
invariably considerable—coming from a Avound of soft parts which are
not only unusually vascular, but besides unfavourable to natural hemo-
statics, as formerly explained—and the patient's state of system is
generally such, in the advanced stage of necrosis, as to be altogether
intolerant of a repetition of such hemorrhages. Therefore, on this last
ground alone, it is plain that the operation for removal of a sequestrum
should never be undertaken, unless the surgeon be tolerably certain
that his effort will then prove successful. During the whole stage of
separation betAveen the dead and living bone, Nature is to be left
entirely to herself; the surgeon being only an interested onlooker;
prepared to Avard off inflammatory re-accession, by suitable antiphlo-
gistics, should that threaten to occur ; and careful to limit motion, in
order to avert fracture or bending of the changing member. From
time to time, he may, by his finger or probe, ascertain the rate and
extent of progress, yet using all most gently ; but all rudeness of ex-
amination must be carefully escheAved, as being prone not only to
interrupt the formation of the substitute, but to extend anew the limits
of the necrosis.
So soon as the sequestrum has become loose, by Nature's effort—not
later, and not before—the surgeon is called upon to take the necessary
steps for its removal. An incision is made through the super-imposed
soft parts ; neither too free, causing unnecessary loss of blood ; nor too
limited, obstructing the subsequent procedure by want of space.
Through the cloaca or cloacae, the extent and form of the dead portion
or portions are then ascertained ; and if the natural opening afford space
enough, through this the forceps are introduced, and the sequestrum
seized and extracted. It usually happens, however, that the natural
openings are not sufficient; the sequestrum proving large, and having
become well and on all sides invested by stout cortical formation.^ It
may be necessary, therefore, to convert two cloacaeinto one, by either
the saw or cutting pliers ; or one cloaca, whether in the old or new
23*
270
PRINCIPLES OF SURGERY.
bone, may be enlarged to the required extent, by the cutting pliers, or
more suitably in most cases by the trephine. Then, the laying hold
of the dead part comes to be of some consequence. Forceps are the
best adapted instrument; but in general they are used much too small
and feeble. The common dressing-forceps, as found in the ordinary
pocket case, are quite unsuitable, except for very small sequestra,
wholly unconfined by cortical formation ; strong blunt pliers, made for
the purpose, should be employed ; like bell-hangers' pliers, only longer
in both blade and handle, with the former well serated to prove surely
prehensile, and powerful in every part. With them, the dead portion
is firmly grasped, and moved to and fro so as to ensure its freedom
from the surrounding substitute ; and then by a steady pull it is brought
to the surface, the leverage poAver being used if need be to break up
any further obstacle which may obstruct its final removal. This saves
pain, time, blood, and trouble ; for the smaller and shorter instrument
is prone to slip ; only after repeated efforts is a truly secure hold
obtained ; and thus often much wriggling and real force are required
to overcome unexpected obstacles by unequal means. When the
sequestrum is long, and the main aperture towards rather its middle
than either extremity, extraction is often much facilitated by cutting
through its centre with the bone forceps, and then extracting each por-
tion separately.
Thus, then, the errors most likely to occur in the manual treatment
of necrosis are three ; too early an interference, ere the natural process
of separation has been accomplished ; attempted removal of the dead
portion, Avhen loose, by adequate means; and the leaving of it un-
disturbed, when loose, throwing on Nature the labour of extrusion as
well as of separation. That the last is an undoubted error is very plain,
when we consider that the sequestrum, when loose, is to all intents and
purposes a foreign body, and as such will be regarded by the living
parts ; creating much local disturbance, and serious inroad on the con-
stitutional power; both unnecessary. By some it has been urged in
defence, or at least in palliation, of the indolent system of treatment,
that there is a possibility of disappearance of the dead portion ; in one
of two ways, either by absorption, or by solution in the purulent fluid
in which it is soaked. That such hope is altogether futile, from either
of these events, has been abundantly proved to demonstration. A por-
tion of bone detached from the living is plainly not amenable to absorp-
tion, unless by solution it be presented to the absorbent vessels in a
fluid form ; and direct experiments, more especially those of Mr. Gul-
liver,* have clearly shoAvn that dead portions of bone are wholly in-
soluble in the purulent or other fluids, to which in a living part they
may be exposed. A dying portion of bone may be partially absorbed,
or disintegrated by ulceration ; but dead bone is liable to neither ab-
sorption nor disintegration, nor any other vital action. Because a large
cavity is found in the interior of a bone, either altogether empty, or
containing but a few minute sequestra, we are not thence to infer that
the cancellated tissue originally occupying this space has first died and
* Medico-Chirurgical Transactions.
ON NECROSIS.
271
then been absorbed ; it has parted with its vitality, doubtless, not how-
ever in a continuous mass, but in molecules, not by necrosis but by
ulceration ; and though the dead portions have been removed, they
have not been taken back into the system, but pushed forth through
the external opening.
At one time it Avas proposed to apply nitrous or other acid to the
sequestrum, with a view to its becoming pliable through loss of its
earthy matter, and so capable of being gently pulled away, at the cost
of but little pain or blood. The impossibility of confining the acid's
action to the part to be destroyed, is a sufficient, because insuperable,
objection to the practice.
When the sequestrum has been removed by operation, the wound is
stuffed moderately with dry lint, partly to arrest the bleeding, Avhich
otherwise might prove profuse ; partly to ensure the wound's ultimate
closure, by a gradual filling up from the bottom. The antiphlogistic
regimen is rigidly maintained for some days, as a certain amount of
inflammatory action is an inevitable result of the interference, however
gently and skilfully conducted, and it being evidently of much import-
ance to keep such action within moderate limits; otherwise the act of
removing one dead portion of bone, might become the means of in-
ducing the formation of a second, perhaps more extensive. The limb
is kept quiet, free from motion and the support of weight; for as yet
the substitute is hollow, imperfect, consequently weak, and prone on
the application of either motion or weight to give way by either frac-
ture or bending. Not till some considerable time has elapsed—varying
in different cases according to the different circumstances of each—
does consolidation of the substitute occur, sufficient to restore not only
the appearance but the function of the bone affected ; and not until
then should the patient be permitted to employ the limb Avith any de-
gree of freedom. And indeed in many cases, in which the temporary
weakness of the new formation is peculiarly manifest, it is well not to
leave the immunity from function at the discretion of the patient, but
to insure this and at the same time afford an adventitious support from
without, by incasing the affected portion of the limb in splints and
bandaging. And similar care is not unfrequently demanded, during
the latter part of the stage of separation ; for then too the bone is very
weak, and prone on exertion either to bend or break. Let not, hoAV-
ever, the limb be kept constantly rigid and unmoved; from time to
time, let the articulations be supplied by a gentle and passive motion ;
otherwise stiffness, or even actual change of structure by disease, may
be induced.
Superficial exfoliation may sometimes be hastened ; but this is but
an exception to the general rule of non-interference previous to the
completion of detachment. When a thin shell of bone, for example,
is coming sloAvly away from the calvarium, it may sometimes be ex-
pedited by applying an escharotic, as the red oxide of mercury, or the
chloride of zinc ; taking care that the application is limited to the dead
portion and its very immediate vicinity. By combining a more con-
tinuous and direct death of the living margin, with its molecular disin-
tegration, the loosening of the sequestrum will plainly be facilitated.
272
PRINCIPLES OF SURGERY.
Again, after detachment has been completed, a superficial exfoliation
may seem fixed. It cannot be by cortical formation, for in the skull this1
is seldom if ever produced. It may be the result either of redundant
granulation or of atmospheric pressure. Granulations may have spruno
up from the surrounding parts, both hard and soft, but especially from
the latter, to such an extent as to partially overlay the dead portion of
bone ; confining it to its place, even though wholly freed from attach-
ment beneath. In such a case, the redundant soft parts are to be freely
pushed aside by the knife or probe; and the bone, thus liberated, is
removed. The atmospheric pressure, Avhen the cause of undue reten-
tion, may be overcome by fixing a screAv in the dead part, thereby
elevating one portion so as to admit the air beneath ; then it is loosened
in every Avay, and can be readily lifted from its place.
Amputation is sometimes demanded, though rarely, in necrosis. It
is the exception, not the rule. It may happen that in the acute necro-
sis of the young, violent inflammatory is followed by severe irritative
fever, and that both are quickly succeeded by a formidable hectic,
which must plainly be relieved at all hazards by removal of its cause;
and under such circumstances it may become not only expedient but
imperative to take off the limb, only a short time after the first acces-
sion of the disease, while the recently dead bone is yet freshly bathed
in pus, and when the process of separation has but just begun. Or in
the more chronic cases, a like summary procedure may be required at
a far more distant date ; after not only weeks but months have elapsed;
when the separation has become far advanced, but is not yet complete;
after the system has for long borne up nobly under the exhausting bur-
den of irritation and discharge ; but when, nevertheless, it has evi-
dently become unequal to a prolongation of the contest. Such cases,
however, it is great happiness to remember, constitute but a small
minority. The greater number are prosperous in their issue, if duly
conducted ; the system Avhich has borne up long, is enabled to sustain
its task till the completion ; the dead part is separated and discharged;
the substitute condenses and solidifies ; the SAvelling of the soft parts
subsides; purulent formation diminishes, and the apertures in both
hard and soft parts are closed ; the limb is not only saved, but is useful
as before. On the one hand Ave must beware of sacrificing life, in vain
endeavour to save a limb ; and, on the other, Ave must be equally care-
ful not to sacrifice a limb, in our anxiety to succour life not yet brought
into actual danger; a dilemma in practice, from whose horns Ave can
extricate ourselves only by a happy combination of knowledge, judg-
ment, and experience. And in relation to this subject, it is important
to remember, that necrosis is not ahvays as extensive as it seems; dis-
charge may be copious, fistulae numerous, soft parts extensively in-
volved, and constitutional disturbance great, and still the sequestrum
may be of but limited extent both in surface and in depth.
Recourse to amputation may also become advisable, in the case of
extensive death of a bone throughout its Avhole thickness, when the
expected reproduction has failed ; the limb then bends, shrivels, and
is worse than useless ; its removal becoming a matter of expediency in
the eyes of both patient and practitioner.
ON NECROSIS. 273
In consequence of neglect, a limb may be presented to us much bent,
and otherwise deformed, with a large blackened sequestrum partially
protruded from the surface. The appearance maybe altogether so un-
promising, as to lead a hasty and inexperienced observer at once to
advise amputation. But this is never Avarrantable, under even such
circumstances, unless the system be already sunk very Ioav, and plainly
unable to bear a prolongation of the strain. Then Ave amputate to save
life ; but in the majority of the examples Ave ought to save both life and
limb. The sequestrum is removed, Avith an expenditure of as little
blood as possible ; the limb is laid in splints ; the bending is gradually
undone by bandaging ; by suitable diet and medicine constitutional
power is maintained ; and thorough restoration of the limb is ultimately
obtained.
It will be observed that I have refrained from entering on the dis-
cussion of a much vexed question in regard to necrosis ; namely, the
exact mode Avhereby the new bone is constituted. I believe that, in
internal necrosis, the formation of the neAV structure, to supply the
deficiency of the old, is invariably the Avork of the parent bone ; and
that in both external and general necrosis, the substitute consists of
two parts, superficial and deep, the one the product of the old bone, the
other begun by the old bone but continued and mainly elaborated by
the periosteum. Whether this cortical or external portion is entirely
formed by the periosteum ; or Avhether the plasma is orginally furnished
by the surface of the old bone immediately before its death, and the
periosteum is subsequently intrusted Avith its nourishment, and the
management, as it Avere, of its transitional organization into bone—we
are not yet in a position to determine. For my OAvn part, I am strongly
inclined to coincide Ayith those who give to the periosteum the poAver
of both furnishing the plasma, and conducting its ossification ; for, the
early death of the original bone, and the suppurated condition of its
periosteal connexion—a profusion of pus usually separating the surface
of the bone from the membrane, and that at an early period—seem
tolerably conclusive as to the improbability of a plastic deposit being found
in the suppurated locality. But, fortunately, the settlement of this mat-
ter of theory is comparatively unimportant, Avhile all are agreed on the
practical question, namely, that the existence of the periosteum, in a
more or less perfect state, is at least essential to the cortical formation.
Whether the plasma be the production of the membrane or of the bone,
the membrane is necessary for its ossification. And hence the necessity
of preserving the integrity of that membrane by every means in our
poAver. It cannot be kept continuously entire, nor is it desirable that
it should ; matter has extensively and acutely burroAved beneath it, and
for the discharge of that matter it must give way at one or more points.
Incision cannot be made too early, both to avert the destructive con-
sequences of an acute abscess pent up Avithin unyielding textures, and
to substitute the comparatively minute aperture of the bistoury, for the
comparatively wide chasm Avhich Avould result from spontaneous ulcera-
tion ; perhaps even a mass of the membrane in the state of slough might
come away, as sometimes, nay often, happens to fascia, under similar
circumstances. A certain amount of aperture is essential; Ave find the
274
PRINCIPLES OF SURGERY.
existence of cloacae—and these, as formerly stated, depend on deficiency
of the periosteum—in all respects beneficial; but we desiderate no largj
chasms in the cortical formation ; on the contrary ; and therefore it ii
that Ave are careful to preserve the periosteum by early and free incision,
so soon as suppuration has formed.
VI.—FRAGILITAS OSSIUM.
Bones are most brittle in youth and in old age ; but more especially
in the latter. The proportion of earthy matter is unduly increased; no
actually, but relatively ; the oily matter is found in unusual quantity ■
the osseous texture is lighter and more spongy than in health, and b)
interstitial absorption the external laminated portion has been very much
diminished ; in truth the bone may, in this unnatural state, be said to
consist of cancellated texture, filled by an oily substance, and surrounded
externally by a thin brittle lamella.
Such degeneration is apt to folloAV long confinement, both in those ol
advanced years, and in those of middle age Avho have indulged freely
and habitually in spirituous liquors ; and more especially Avhen the con-
finement is the result of rheumatic affection. During the progress of
confirmed cancerous disease, too, it is not uncommon. Also, the
cachectic states induced by the mercurial and syphilitic poisons, seem
manifestly to favour the occurrence of such change in the skeleton; and
both scurvy and struma may sometimes be not unjustly suspected of a
like sinistrous tendency. The exciting cause need be but a slight one;
a hasty or inadvertent step, turning in bed, rising from the seat or from
the knees, a trip on the carpet, or any sudden muscular exertion, may
suffice.,
Treatment.—When children labour 'under this affection—as they
comparatively but seldom do—the existence of a cachexy identical
with the scrofulous is to be suspected ; and by the judicious and per-
severing employment of treatment suitable for the removal of this, the
predisposition to fracture from slight causes may after a time be wholly
averted. But in those of advanced age, it is othenvise ; the predis-
position, and the altered state of the skeleton remain; all that can be
done in prophylaxis, is to guard against the occurrence of the excitiri"
causes ; and at the same time we may endeavour to prevent increase oi
the cachectic state, by a carefully regulated yet nutritious diet, and
exposure to a salubrious atmosphere. When fracture has occurred, the
part is to be arranged carefully as in ordinary cases of that accident. It
may be that reunion Avill not occur; it is more than probable that, when
it does take place, the process will prove very tedious and the result
imperfect; a second or third fracture may occur, during the treatment
of the first; the constitution may suffer and sink, and perhaps so rapidly
as not even to permit the more than doubtful chance of amputation ;
yet it is plainly our duty to permit no anticipation of such untoward
consequences to influence the care and attention bestoAved on our
management of the case. Let our treatment be, if possible, more
ON MOLLITIES OSSIUM, OR OSTEOMALAKIA. 275
pains taking than in ordinary circumstances ; and it is not unlikely that,
in a fair proportion of such cases which come under our observation,
our care may be rewarded by a prosperous conclusion. During the
attempted cure, much judgment is required in both the general and
local management. Locally, Ave Avish by bandaging and splints to keep
the fragments in close apposition and absolutely immoveable ; constitu-
tionally, Ave are desirous of supporting the vis vitae,.by generous food
and other tonics, perhaps freely administered ; but to folloAV out these
indications blindly and with rashness, is almost certainly to induce
chronic gangrene of the extremities—analogous to one form of the
gangrena senilis, over-action occurring in a part and system both of
much diminished power. The bandage and splint must be only mode-
rately tight, the diet must be nutritious yet non-stimulant; the effects
of both must be carefully watched ; and should the gangrene appear
notwithstanding all our care, the fracture must for a time be compara-
tively disregarded, and our attention mainly directed to the mastery of
the more serious malady, according to the principles formerly detailed.
When fracture has occurred in consequence of the cancerous diathesis,
often a malignant tumour forms at the site of injury, instead of the
normal callus. But that result is by no means invariable, and therefore
even in those unpromising cases our treatment should still be the same,
or even more careful than in ordinary fracture.
VII.—MOLLITIES OSSIUM, OR OSTEOMALAKIA.
Both this disease and rickets differ from the foregoing affection, in
being characterized by a deficiency, both actual and relative, instead of
an excess, of the phosphate of lime. In mollities ossium, the skeleton,
originally of a normal structure, parts Avith its earthy matter, becoming
soft and pliable in consequence. In this respect there is a manifest
difference from rickets, in Avhich the osseous structure is anormal from
the first, or at all events from a very early age. In rickets, also, soften-
ing and flexion are sIoav and gradual; in mollities ossium, the progress
is rapid, and the distortion may be both instant and great. Further, in
rickets, after a time, the anormal condition is departed from, earthy
matter comes again in even more than its due proportion, the skeleton
becomes solid and unyielding, and the general health may be in a great
measure restored; in mollities ossium, the untoAvard progress is stead-
fast, there is no amendment in the state of either health or skeleton, and
the disease sooner or later proves fatal. Again, the one disease is
most common in childhood, while the other is peculiar to maturer years.
Mollities ossium occurs more frequently in females than in males ; hap-
pily, however, it is a rare affection in both. Rickets, on the contrary,
seems to have no predilection for either sex, and is extremely common.
In this disease the loss of earthy matter is both rapid and great; and
a copious phosphatic deposit is found in the urine. The general health
is much and hopelessly impaired ; flesh, spirits, and strength diminish-
ing daily. The bones are light, soft, and greasy ; and ultimately may
276
PRINCIPLES OF SURGERY.
come to consist of a thin external shell, filled with soft matter, partly
lardaceous partly oily. Sometimes much pain attends, in other cases
the unfortunates suffer little or no inconvenience ; in one remarkable
instance, related by Mr. HoAvship, a sense of tightness and much pain
were complained of at one particular spot, and there on dissection a
marked constriction and depression of the softened bone Avere found.
The cause of mollities ossium is still involved in obscurity. Loss of
blood, mercurialism, and whatever depresses constitutional poAver, are
believed to predispose toAvards its occurrence. In the case of Madame
Supiot—a memorable example—the eating of much salt Avas a promi-
nent peculiarity, Avhich some Avere inclined to specify as a cause ; but
it seems to have been rather an accessary of the general perverted state,
than its origin.
The disease is according to present experience, incurable. And, as
in other affections of a like nature, all that can be aimed at in treat-
ment, is a palliation of the more prominent and distressful symptoms.
VIII.--RICKETS.
As formerly remarked, this is an original vice of the skeleton, pecu-
liar to early years ; if it be not apparent at the time of birth it becomes
manifest speedily thereafter, during early childhood. It is attended from
the first by a marked cachexy of system, Avhich is doubtless identical
with the scrofulous. Usually, hoAYever, this becomes abated, after a
time, and that even independently of remedial treatment; and, cotem-
poraneously Avith the amendment of general health, the anormal condi-
tion of bone also disappears—a fact which has a most important bear-
ing on the treatment, and Avhich should therefore be borne constantly
in remembrance.
The bone is found changed in structure, much in the same way as in
fragilitas ossium ; but, instead of a brittle condition, the result is soft-
ness and pliability. The dense laminated texture is almost entirely re-
moved, barely enough being left sometimes to constitute a thin out-
ward shell; cancellated texture consequently largely predominates, of
a brown or reddish hue, soft, compressible, and filled with an oily fluid;
or a thin sanious liquid may be squeezed out, as if from wet leather.
Sometimes the entire bone is expanded, even to a great extent; the
calvarium, for example, being in some cases found of more than dou-
ble its usual thickness, and seeming to consist almost entirely of diplce;
sometimes atrophy is the prominent change : in all cases, Avhether atro-
phy or expansion exist, the bone will be found much lighter than Avhen
in the normal state. The flat bones are perhaps more frequently thick-
ened than otherwise ; the long bones usually are atrophied in the shaft,
Avhile they show hypertrophy of the articulating extremities. Such en-
largement, hoAvever, is often more apparent than real, depending mainly
on the Avasting of the shaft and its soft coverings.
Although the whole skeleton may have thus degenerated, it h ob-
vious that those bones ayHI evince the vitiated condition most which
ON RICKETS.
277
are most exposed to muscular action, and to the sustaining of superin-
cumbent weight. Consequently, we find the spine and lower limbs
most prominently distorted. The former may be bent fonvard, or to
the side; usually the curvature is lateral, with more or less rotation of
the bodies of the vertebrae. Antero-posterior bending has occurred to
such an extent as to cause a doubling of the aorta, adhesion of the
opposed coats at the folded part, and consequent mal-nutrition of the
lower limbs. The thighs and legs may have their natural curves merely
exaggerated, or they may be bent in a variety of fantastic ways. Their
bones, hoAvever, are not only bent but flattened; and, fortunately, the
greater diameter of the bone is anterior-posterior in relation to the
curve ; consequently, they are not so Aveak as they otherwise Avould be.
The pelvis is, as it were, crushed together ; the promontory of the sa-
crum and the acetabula seeming desirous of meeting at a common cen-
tre. The ribs follow on the spinal distortion, variously accommodating
themselves thereto ; usually so as to produce a marked and even sharp
prominence of the chest, which is greatly contributed to by a bending
forwards of the sternum. The clavicles have their natural curves in-
creased ; the scapulae are not much changed, except in shoAvinor en-
largement of the articulating surfaces. The bones of the arm and fore-
arm are tAvisted more or less, but retain much more of their normal
character than do the lower extremities; the one set having to bear
muscular effort alone, Avhile the other has to contend Avith both this and
superincumbent Aveight. By the alteration in the important visceral
cavities, breathing is oppressed, and the assimilating organs are more
or less embarrassed ; usually the abdomen is preternaturally prominent.
The stature is stunted, dAvarfish, and unseemly. Besides, there are the
usual characteristics of the scrofulous .diathesis. The head is usually
large ; the features marked, and developed with an unpleasant fulness ;
the general expression of face displeasing, and altogether so peculiar,
as to be almost pathognomonic of the general disease. Although there
may be unusual thickness of the skull, yet this is to be understood only
in its literal sense; for often the intellectual poAver is vivid and great.
The predisposing cause of rickets, as formerly stated, seems to be a
vitiated state of system, analogous to that of scrofula. The disease
may shoAV itself at or soon after birth ; but perhaps, more frequently the
exciting cause is some of the debilitating accidents incidental to child-
hood—as dentition, or some of the host of infantile disorders therewith
connected. Very often, the change in the skeleton is first observed,
on the child's attempting to walk; and then primary deformity is of
the loAver limbs, chiefly below the knee. The knees approach each
other, the ankles diverge, and the shins curve forwards over the
ankles; a very different kind of bending from the ordinary bandy ap-
pearance, a mere exaggeration of the natural tibial curve, which so
often occurs in the heavy, but healthy child, Avho, perhaps prematurely,
has begun to struggle into the erect posture. After the lower limbs,
the spinal column begins to yield ; and then follow the other component
parts of the skeleton ; the multiplicity of bones affected, being one of
the characteristics of this constitutional disorder, and serving to distin-
guish it from curvature of single bones—of the spine more especially—
21
278
PRINCIPLES OF SURGERY.
which do not depend on rickets, or any other vice of the general sys-
tem. In the case of the spinal column, it is most especially important,
in practice, to remember that many examples of its bending arc inde-
pendent wholly of rickets; and that those cases alone are ricketty, in
Avhich the system is plainly and primarily cachectic, and in Avhich the
deformity, by bending, is not limited to the spine alone, but affects
other bones as well, more especially the ribs, pelvis, and loAver extremi-
ties. This is a practical point, however, which will be more fully
dwelt upon, when treating specially of spinal curvature.
As the ricketty patient advances in years the disease does not pro-
portionally become more marked, as is the ease in mollities ossium.
But at, or after puberty, if not before, the phosphatic deficiency is found
to cease, the general health amends, flesh and colour are gained, the
spirits rise, motion is more sought and better performed, the skeleton
is found to be hardening in its texture ; nutrition has begun to be re-
stored, and is gradually approaching the healthy standard. If means,
suitable and successful, have been adopted, ere this, to undo the curves
and restore straightness and symmetry of form, the firming of the skele-
ton is an unqualified boon ; but if, as is not unlikely, the remedies have
been either wholly absent or imperfect in their operation, one result
inevitably is an irrevocable confirmation of the existing deformity.
This, hoAvever, is in some degree ultimately atoned for. The general
health is regained, as also power of motion to a certain extent; the
muscular fibre becomes fully developed, and the muscles adapt them-
selves to the shortened and bent bones ; the bones though mis-shapen,
are strong ; and yield no longer, to either muscle or weight; they con-
tain at least the normal proportion of earthy matter, and besides have
been strengthened in their curves by neAV bone deposited, sometimes
copiously, in the concavity ; the pelvic and thoracic viscera accom-
modate themselves to the altered circumstances of their including ske-
leton. And thus, the patient, though a confirmed and unseemly dwarf,
weak and puny in his boyhood, may notwithstanding prove a healthy,
muscular, and tolerably active man.
Treatment.—The treatment of rickets must be mainly directed to-
wards the amendment of the general system, as is plain from a con-
sideration of the nature and cause of the disease ; and, the inductive
cachexy seeming to be identical with the scrofulous, a general treat-
ment Avill be expedient regarding diet, exercise, clothing, tonics, &c,
similar to that formerly recommended as tending to subdue the strumous
diathesis, and to prevent the establishment of local strumous disease.
Friction of the general surface is of use, tending to improve the skin,
and at the same time to promote muscular development; muscular ex-
ercise too will assist in the fulfilment of the latter indication, but it
must be both gently and briefly practised, othenvise the skeleton can-
not fail to have its distortion increased thereby. Absolute confinement
to the supine posture will do more, harm than good, by aggravating the
constitutional debility and general disorder; but its occasional use, for
an hour or two at a time, or even for that period only which is usually
allotted to Avaking repose, will be founcl of much service, relieving the
weak spine and loAver limbs from the weight imposed by the erect and
ON RICKETS.
279
semi-erect postures. If the spinal column continue to bend, notwith-
standing the persevering use of the suitable constitutional remedies, as
well as relief by posture, light mechanical support becomes essential.
Not by the heavy cumbrous stays, ordinarily employed, at least in times
not long by-gone; an apparatus under which it Avould require the
strength of a stalwart man-at-arms to move Avith comfort; and the mise-
rable^ effect of which on the delicate and Aveak patient must ever be in
the highest degree disastrous. But by a light and easy adaptation of me-
chanics, such as the Avell-informed modern artist now supplies; the ob-
ject of which is to relieve the spine from the weight of the head, arms,
and trunk by taking it upon itself; Avhilst yet no cramping of muscles is
felt from a tight unyielding embrace, nor lassitude, fatigue, and abso-
lute pain induced by an umvieldly and overpowering encumbrance.
The principle of construction is simple ; light steel rods, supporting
weight between the axilhe and the pelvis, leaving the spinal column
free. In the use of all mechanical supports, however, let the soft and
yielding state of the whole skeleton be remembered, so that we may
if possible, not only relieve the parts most oppressed, but also do no
harm, by undue compression, to those parts on which the duty of sup-
port is temporarily thrown. It Avoukd be but a bad result, in attempt-
ing to straighten the spine, to crush the pelvis. When the loAver limbs
are but little bent in the puny child, and the ricketty condition is
scarcely yet fully developed, no mechanical apparatus should be
adapted ; the general treatment is to be earnestly employed, moderate
exercise is to be encouraged, the patient should be much in the open
air, :md diet should be free and nourishing; and generally in such cases,
the little patient, in common phrase, grows out of the deformity; the
limbs spontaneously resuming strength and symmetry. But when the
curvation is great, and ia other respects the ricketty indications un-
doubted, light apparatus are certainly expedient; as fulfilling three
salutary indications ; preventing increase of the deformity from bending;
diminishing that Avhich has already occurred, by applying reducing
power in the required direction and degree ; and enabling out of door
exercise to be enjoyed, much to the advantage of the general health,
and yet Avithout prejudice to the limbs. And in regard to this ortho-
pcedic treatment let it always be remembered, that the time for its ap-
plication is but limited ; that if the present opportunity be not improved,
the period is probably fast approaching Avhen, by a complete change in
the diathesis, the bones become no longer pliable and yielding, but,
resisting all remedial efforts, have their deforming curves permanently
confirmed. The suitable mechanical apparatus need not be minutely
described ; the details require to vary in almost every case ; the prin-
ciples of their construction and the superintendence of their use con-
stitute the surgeon's duty, the rest is left to the skilful and intelligent
machinist.
In curvature of the spine, not of ricketty origin, but depending on
either muscular debility, or awkwardness of muscular play induced by
careless and improper attitude, benefit is sometimes obtained by main-
tenance of the strictly erect posture, during a certain number of hours
•n the day, and by the poising of a light Aveight on the crown of the
280
PRINCIPLES OF SURGERY.
head • but in rickets, ponderation of any kind will tend to prove an
adjuvant not of the cure but of the disease ; the principle of the former,
is not the imposing, but the abstracting of weight from the enfeebled
column of support.
To the ricketty female, celibacy must be strictly enjoined ; for unfor-
tunately an " aptitude for conception" often exists, along with pelvic
change and other circumstances extremely hostile to parturition.
Phosphate of lime has been given internally in a sustained course of
large doses, but obviously with a lack of wisdom ; there is no want of
earthy matter in the system, but only in the skeleton ; and as yet we
have got no means of directly precipitating lime either upon or into
the living osseous texture.
A chemical view of the nature and treatment of the disease has
lately been broached. " Phosphate of lime is eliminated in large quan-
tities with the urine. This salt, otherwise little soluble, and discharged
generally only in small quantity by the kidneys, is, according to Ber-
zelius, readily soluble in lactic acid; any thing therefore which causes
a super-abundance of this acid in the system is capable of depriving
the organism of a large share of the earthy matter of the bones. Sugar
of milk, grape sugar, starch, and gum, are readily converted into lactic
acid, but they are so in the stomach only when digestion is ill-per-
formed, in which case lactic acid may be an abundant product in the
system. Rickets and mollities ossium therefore.........may be^ the re-
sults of imperfect digestion and nutrition ; to improve which is conse-
quently our first indication. None of the substances readily converted
into lactic acid should be taken, as sugar, starch, gum, &c, nor even
milk; but animal food should be chosen, and such other as is of easy
digestion, in aid of which we ought to employ such medicines as may
restore the general tone of the system."*
According to this view, scrofulous children may perhaps be saved
from the accession of rickets, by early weaning, and careful attention
to other diet—less prone to acid, yet equally nutritious.
CHAPTER IX.
DISEASES OF THE JOINTS.
Formerly all the graver examples of diseased action in joints were
included under one common designation, " Avhite SAvelling ;" a custom,
scarcely convenient, Avhich led to much confusion and inaccuracy as
to the nature of the affections, and to at least uncertainty in their
* Marchand. Lancet, No. 1034, p. 438.
ON SYNOVITIS.
281
treatment. But, thanks to the labours of modern surgeons, among
whom in this department the name of Sir Benjamin Brodie stands pre-
eminent, all such confusion and uncertainty have been dispelled ; and
each disease, set forth in its proper site and character, may have its
appropriate remedy or system of treatment assigned. As can be readily
understood, however, such discrimination can only be practised, while
the disease is yet comparatively recent: for, after a time, the morbid
action, in whatever texture it may have originally dwelt, involves the
whole articulating apparatus in one chaotic mass of disease. It is
during the comparative infancy of the disease, that any treatment is
most likely to prove successful; and it is so far fortunate, that it is
at the same period Ave enjoy a facility of discrimination and accurate
diagnosis.
We shall consider, in succession, the results of the inflammatory pro-
cess in the different component textures of the joints ; 1. In the Syno-
vial Membrane; 2. In the Cartilage; 3. In the Bones.
Synovitis.
By this term is meant the inflammatory process occurring in the
synovial membrane, a tissue in many respects resembling the serous,
both in health and disease. The action may be either acute or chronic.
I. Acute.—The inflammatory process tends to spread from one part
over the Avhole membrane, to assume an intense character, to be ac-
companied Avith much exudation, and to result in serious change of
structure. At first the membrane becomes congested, turgid, and
shoAvs an apparent increase of vascularity ; the natural secretion is
poured out in increased quantity, and of a more aqueous character than
in health. This necessarily causes general SAvelling of the part, Avhich
forms almost synchronously Avith the first painful indication of the ac-
cession of the morbid action—an occurrence, diagnostic of the affec-
tion. Then, the membrane begins to change in structure, by interstitial
exudation; it becomes thickened, soft, red, almost pulpy, and loses
its translucency, as Avell as the smooth glistening appearance of its
internal surface. At this time, the effusion ceases to be chiefly serous,
and contains more or less of fibrin, usually floating about in detached
flakes; and also the fibrin is found beginning to adhere to the surface
of the membrane, as Avell as to be deposited in its parenchyma. It is
at this stage of the process that adhesion may occur betAveen tAvo op-
posing portions of the membrane, or extensively so as to obliterate a
large part of the joint's cavity. But this result is of comparatively rare
occurrence, probably for tAvo reasons: first, the action usually tends
rapidly onAvards, and soon overpasses the opportunity for plastic forma-
tions, quickly arriving at the suppurative and ulcerative stage ; second,
because the presence of much fluid in the joint is plainly inimical to
adhesion, the surface being separated by the distention. Subsequently,
as the suppurative crisis is approached, and also after it has occurred,
the change of structure increases ; the membrane is not only thickened
and changed in itself, but becomes incorporated with the plastic exu-
dation which has adhered to its free surface, and which by partial
24*
282
PRINCIPLES OF SURGERY.
organization has assumed a membraneous appearance and function.
This layer of false membrane, as it is termed, is in all respects analo-
gous b/the pyogenic membrane of the ordinary acute abscess ; by the
exercise of its newly assumed function, purulent secretion i3 continued
in greater or less quantity; at first it mingles with the serum already
within the synovial pouch, and the contents are sero-purulent; but
soon the serous character is altogether merged in the purulent, the
thinner portion of the fluid having probably been absorbed. Through-
out the Avhole period, the super-imposed soft parts have been sympa-
thizing closely ; themselves involved in a minor grade of action, and
consequently becoming SAvoln and infiltrated thereby.
The symptoms Avhich accompany these results of the inflammatory
process are sufficiently distinct. Pain is early and severe ; it is con-
stant, and, gradually increasing in severity, ultimately becomes intense.
There is swelling, also gradually on the increase, sometimes becoming
great; and, as already stated, its accession is synchronous with that of
the pain. The swelling is not altogether uniform, but is much more
so than in the chronic form of the affection. The joint naturally be-
comes most prominent at those points Avhere there is least resistance ;
in the knee-joint, for example, we find the bulging to be chiefly late-
rally and beneath the tendon of the quadriceps muscle. But then such
peculiarities of tumour become very much obscured and masked by the
general oedematous SAvelling of the superficial parts. The skin is red,
tense, hot, and sensitive. The pain is general, pervading the whole
part, but greatest in the interior ; much aggravated by pressure, and
altogether intolerant of the slightest motion. A position is assumed,
naturally, in which the parts affected are most relaxed, and pressure
removed from the opposed surfaces ; relief is felt from this posture, and
it is not only involuntarily assumed but maintained. Also the muscles
in the neighbourhood are found somewhat involved; their tonicity is
increased, as evinced by firm solidity of the muscular fibre, and rigidity
of the tendon. For example, in the inflamed knee, we find the joint
in a state of semi-flexion, with the ham-strings tense and hard as cords.
The muscles are liable to spasm also, Avhereby involuntary startings of
the limb occur, especially during the short and uncertain periods of
disturbed sleep; and the jerking motion thereby occasioned, all the
symptoms are much aggravated. The constitution labours under in-
flammatory fever of a grave kind, which increases with the progress
of the local disorder. On suppuration having occurred, there is marked
aggravation of all the symptoms, both constitutional and local, and a
succession of rigors usually ushers in the exacerbation. The fever
rises higher, and the system is proportion ably more oppressed; the
swelling is larger and more tense ; the pain, heat, and feeling of tight-
ness are increased, accompanied Avith a deep-seated throbbing, and
each pulse seems still farther to augment the pain. The superficial
swelling becomes of a more urgent character, being the result now of
a higher grade of action. The fluctuation within the joint also changes
its type, and affords to the experienced touch a tolerably certain indi-
cation of pus, not of serum. At one or more parts, the swelling begins
to point; the matter now approaching the surface, by ulceration and
ON SYNOVITIS.
283
absorption of the intervening textures. Ultimately the integument at
the prominent points either gives way or is opened artifically, the mat-
ter is discharged, and the joint's cavity is free to the external air. For
a short time, immediately subsequent to the evacuation, the more
urgent symptoms subside, by the relief of tension; but very soon a
second aggravation generally ensues, even greater than that which
folloAved on the first formation of matter; a fresh inflammation, as it
were, seizes on the parietes of the abscess, and the destructive process
rages anew, accompanied by violent constitutional disturbance, per-
haps now of the irritative rather than of the inflammatory type of fever.
This, in its turn, is not likely to give way to hectic; the whole joint
having now become a prey to the destructive results of inflammation,
and the system beginning to sink beneath its burden.
Such is the nature of acute synovitis, when its whole course is run.
But it is to be understood that at any* period of the process, the action
may cease its advance and begin to subside, spontaneously or from
treatment; and that the symptoms will vary accordingly.
The disease may originate without any apparent cause ; more fre-
quently it is the result of injury—as bruise or wound. In the latter
case, unless the union be by simple adhesion, synovitis is inevitable ;
for, it being necessary to granulation that the track of the wound should
preAriously inflame, a portion of the synovial capsule inevitably partakes
in that process ; and, as already stated, it is a peculiarity of that tissue
that inflammation attacking a part quickly spreads over the whole.
Whence a plain and practical inference is to be draAvn ; how in the
treatment of wounds of joints it is of the greatest moment to subdue or
avert inflammation, and ensure simple adhesion. Rheumatism is a fre-
quent predisposing cause of synovitis, the action being modified by the
specific diathesis ; and during the prevalence of this diathesis a very
slight exciting cause suffices ; or even this latter may be altogether dis-
pensed with. Exposure to cold often induces the disease, even in
persons previously of the most robust health ; but most readily, of course,
in those filled with rheumatic tendencies. And mercury, among its
many evil results, often remote, is an undoubted and frequent parent of
some of the worst forms of synovitis ; at least, if not both predisposing
and exciting cause, it is certainly the former.
The joints most liable to be attacked are those of the_ extremities;
most exposed to external violence, and to atmospheric vicissitude ; the
knee, elbow, wrist, and ankle ; on the whole, the first is the most fre-
quent sufferer.
Treatment.—The treatment is early, active, and severely antiphlo-
gistic. Blood is taken away conspicuously from the near vicinity of the
inflaming part, by leeches or by cupping; and unless contra-indicated
by other circumstances than those connected with the disease, blood is
also taken from the system, by venesection ; it being obviously of the
utmost importance to check the action at its onset, or at all events to
bring it down to a slower rate of progress, and to a minor grade of in-
tensity. The tissue affected is endowed with both importance of func-
tion and delicacy of structure ; after bleeding, therefore, the exhibition
of calomel and opium is advisable; as being most calculated, by its
281
PRINCIPLES OF SURGERY.
systemic influence, to save structure and consequently retain function.
Should circumstances render mercurialization inexepedient, or at least
hazardous, full doses of the solution of tartrate of antimony may be sub-
stituted. When the rheumatic diathesis is apparent, the colchicum will
be preferable to either ; pushed, in full doses, till its physiological effect
has been at least threatened if not established. The limb is encouraged
to maintain the relaxed posture voluntarily assumed ; and immunity
from motion is anxiously attempted to be secured, by gentle deligation
of the part to soft pillows skilfully and carefully arranged. Purgatives
are inexpedient; as opposed to immunity from motion. Should the
tendency to spasm prove troublesome, opiates are advisable, given in
combination with camphor and hyoscyamus. Fomentation is applied
to the part, regimen is most strictly antiphlogistic ; and in short all the
ordinary details of both that regimen and treatment are rigidly en-
forced.
In the great majority of cases, early seen and judiciously treated, the
action is arrested in its progress, ere the suppurative crisis has been
attained. Then, as ordinarily happens in acute serous effusion, the
work of resolution slowly advances, almost spontaneously; aid from
treatment consisting merely of continued rest of the part, occasional
fomentation, and maintenance of the spare regimen. The absorbents
of themselves are soon busy in clearing away the results ; and in most
cases are equal to the efficient completion of their task. But should
they begin to flag, then they may be assisted from Avithout, by gentle
friction, pressure, stimulating plasters or inunction, or the slightest forms
of counter-irritation ; these however being always adopted cautiously,
and as if with hesitation, lest by their premature use the embers of the
not yet extinct action might again be lighted into a flame.
When action has not only subsided, but its results also have been
removed, motion is to be gradually restored ; at first passive and gentle,
always desisted from when pain is induced ; and invariably both com-
menced and conducted with the same precaution as in stimulation of
the absorbents. Many a limb has been lost, for many a joint has sup
purated, in consequence of re-accession of acute action by imprudent
resumption of motion. It is doubtless an object of very great import
ance that the part's function should ultimately be restored, that the
limb should not be permanently bent, and the joint not permanently
stiff; but an over-anxiety to fulfil this indication will lead us to straighten
the limb, and move the articulation, too much and too soon ; and surely
the safer side on Avhich to err, is to run some hazard of trouble by
threatened anchylosis,—none whatever of rcinduced disease, and pro-
bable disorganization of the part thereby.
During the whole period of cure, up to the time when motion is be-
gun to be restored, all movement in the joint is to be most studiously
avoided. During the acute stage, the part is intolerant of bandages
and splints; then Ave have to trust to pillows, and gentle deligation
thereto beyond the inflamed part. But so soon as the acute stage has
passed aAvay, sufficiently to permit the application of splints, these are
forthwith had recourse to, as being by far the most efficient means of
fulfilling the all-important indication in view. The preferable kind are
ON CHRONIC SYNOVITIS.
285
those of thick leather, softened by immersion in hot water; applied
when pliable—usually one on either aspect of the limb ; retained by
bandaging for a few hours, till they harden into a case closely adapted
to the undulating surface of the part; then removed, and lined by some
soft substance, such as toAV, wadding, or chamois leather; reapplied
with but moderate tightness, and constantly retained.
When unfortunately our efforts to arrest action have failed, and sup-
puration has occurred—the interior of the joint being in truth converted
into an acute abscess—the general rules of surgery are not to be de-
parted from; an early and free incision should be practised. This,
however, it is plain, can only be had recourse to Avhen the symptoms
are so very distinct as to leave not the slightest doubt of suppuration
having occurred. To plunge a bistoury into the cavity of a joint filled
with serous or sero-purulent fluid, would be a most umvarrantable pro-
cedure ; rendering disorganization certain, where otherwise all might
have been saved ; such fluids, and the change of structure which at-
tends on them, being perfectly amenable to absorption. When there
is any doubt, therefore, as to the nature of the contents, Ave withhold
the knife ; if they are purulent, the natural process of pointing will soon
disclose the real state of the matter ; and then incision is unhesitatingly
performed. Should the nature of the contents continue doubtful, the
case having assumed a chronic form, puncture may be made by a fine
grooved needle, subsequently applying exhaustion by means of a cup-
ping-glass if need be, in order to exhibit a portion of the fluid from
within,
After incision, accession of additional inflammatory action is inevitable,
and has to be guarded against accordingly ; the maintenance of rest,
with the other local management, is if possible more assiduous than be-
fore ; and temporary resumption of the general antiphlogistics will pro-
bably be expedient: Afterwards, our expectation is that the cavity will
gradually contract and close, as do other acute abscesses; but, on ac-
count of the peculiar nature of the parts implicated, it is not improbable
that such hopes may be disappointed.
Purulent formations not unfrequently form in the larger joints, in the
latter stage of severe phlebitis. Such cases, however, are altogether
different from the ordinary acute abscess. They are not the disease,
but only a symptom of one infinitely more formidable; under which
latter the system has rapidly given Avay, and is altogether irrecoverable.
The complication by articular abscess, does not cause, but probably
accelerates dissolution—already very near. There is seldom time or
opportunity afforded for treatment of the local malady—even should
that be deemed expedient; but if there should, general principles are
still to be enforced ; a free and dependent incision is practised.
II. Chronic Synovitis.—This may be either simple in its nature ;
or connected with and marked by the scrofulous cachexy.
1. Simple Chronic Synovitis.—It may be original or secondary ; the
inflammatory process may have been chronic from the first; or origi-
nally acute, subsequently assuming the chronic form. The pain, heat,
&c, are comparatively slight. Swelling is the prominent symptom.
286
PRINCIPLES OF SURGERY.
And now the peculiarities of bulging, dependent on the structure of the
joint, come to be distinctly seen—a circumstance diagnostic between
the chronic and acute forms of synovitis—for the super-imposed soft
parts sympathize but little in the perverted vascular action, and conse-
quently cause little or no obscuration of the synovial tumour. The
membrane is thickened, dull in hue, increased in vascularity, and gra-
dually changes its smooth internal aspect into a soft, pulpy, or villous
surface ; the cavity contains more or less of a serous fluid, either jure,
or mingled with a small proportion of a puriform secretion ; this has
accumulated sloAvly, the parts have gradually accommodated them-
selves to its presence, and the process of distention is consequently
attended with but little uneasiness.
Sometimes the process of accumulation is peculiarly indolent and
painless, and yet tolerably rapid in its rise ; the superficial soft parts
are Avholly uninvolved, the Avhole disease seeming to be the product of
a suddenly occurring passive congestion of the synovial membrane, and
limited to that texture ; the fluid is entirely serous, and the form of tho
swelling is very decidedly influenced by the natural configuration of
the joint. This condition is termed Hydrops Artieuli. The knee is its
most frequent seat; and it is most apt to occcur at or beyond the adult
age, and in those who have suffered from mercurial exhibition.
Chronic synovitis, though not in itself important, or urgent in its
nature, is nevertheless fraught with danger by continuance. For, at
any time, but a slight exciting cause will suffice for the induction of
acute inflammatory accession ; and, even supposing that this do not
occur, structure is certain ultimately to be most seriously changed by
the persistence of the present action, chronic though it be; and that
not only in the texture originally involved, but in others to which the
action may gradually extend—the cartilages, and even the bones. In
another point of view also, the affection is important ; Avhen we remem-
ber hoAV much more difficult of satisfactory removal are the results of
chronic than those of acute effusion.
The prominent symptom, as already said, is the unequal, fluctuating
swelling; there are also dull pain or uneasiness, some heat, and great
limitation of motion ; the joint is more or less flexed, and the tendons
of the flexor muscles implicated gradually assume a rigid condition.
The limb by confinement Avastes, and its muscles become small, weak,
and flabby.
When the diseased action is extending to other tissues, and formida-
ble though chronic change of structure is in progress, the SAvelling often
loses its lax fluctuating character ; the thinner portion of the synovial
contents is probably being absorbed ; fibrinous deposit is taking place
both within and without its cavity, and in the substance of the textures
themselves. The swelling consequently becomes more solid and less
fluctuating ; the joint is more painful, and more abridged in motion ;
and constitutional sympathy, before perhaps slight, now becomes con-
siderable—tending toivards the hectic type.
The disease is seldom the result of external violence. More com-
monly it folloAvs on exposure to cold ; or it may be attributed by the
ON CHRONIC SYNOVITIS.
287
patient to some slight twist or strain ; and it most frequently occurs in
those who have suffered by the venereal poison, by the mercurial, or
by both. Rheumatism too is a fertile inducing cause.
Treatment.—Moderate local depletion, by leeching, is at first em-
ployed, Avith rest; not so much on account of a remedial effect expected
from itself, as for rendering the subsequent application of counter-irrita-
tion, on Avhich the main hope of cure has to rest, safe and expedient.
Were this to be had recourse to at once, stimulation and increase of
the chronic vascular action might result, instead of its arrest and sub-
sidence. The preliminary gentle antiphlogistics stop the progress of
the action; the counter-irritation gradually subdues it, and effects its
final extinction ; at the same time favouring disappearance of the anor-
mal deposits, both solid and fluid. The counter-irritants may be varied
according to circumstances; blisters, in succession; croton-oil embro-
cation ; tartar emetic ointment or solution ; or an ointment of nitrate of
silver, strong enough to produce a pustular effect by inunction—are the
most common and suitable forms. When action has fairly ceased, and
all is quiet, then the attention may be mainly directed to discussion, or
stimulation of the absorbents. With this view various discutient plas-
ters may be applied; as the gum plaster, or the mercurial, or equal
parts of both. Or pressure may be applied, either by simple bandaging,
or by combination of this with plaster. The iodide of potassium may
be used in the form of ointment, as Avell as given internally; or a strong
solution of iodine, either aqueous or alcoholic, may be pencilled on the
surface. But still let the effect of these remedies be carefully Avatched,
lest unfortunately over-stimulation be induced. And throughout the
whole treatment let the paramount indication be, rigid maintenance of
absolute rest in the affected part, by splints ; at first lightly applied, so
as merely to prevent motion; aftenvards with tightness, in order by
their pressure to assist in the favouring of absorption. In due time, by
passive motion, cautiously increased, the joint's function is restored.
Constitutional management is not. to be disregarded. Invariably
more or less disorder will be found in the system ; and rectification of
that is essential to due advancement of the cure. If any peculiar
cachexy exist, as is not unlikely, it must be met by the suitable reme-
dies ; obstinate and lurking venereal taint, by an alterative and cautious
mercurial course ; mercurial taint—the more frequent of the two, either
single or combined with the preceding—by sarsaparilla, or the iodide
of potassium ; rheumatic diathesis, by colchicum, &c.
In hydrops articuli, the most trustworthy remedy is iodide, used both
externally and internally. Should it fail, mercury, unless otherwise
contra-indicated, may be cautiously tried in a similar way: externally,
in the form of ointment or plaster; internally, as an alterative course,
mildly and prudently, and as if reluctantly conducted. Or the tartrate
of antimony may be given internally, pushed in almost as full and as
frequent doses as for pneumonia ; this, however, is a harsh remedy,
and not to be employed till others more simple and more usual have
been tried and failed. Locally, acupuncture, with subsequent applica-
tion of the exhausted cupping-glass, has been tried; but the result has
proved unsatisfactory, as to cure; and, besides, the practice is not free
288
PRINCIPLES OF SURGERV.
from the risk of lighting up acute inflammatory action. And a similar
objection will apply to simple acupuncture, practised with the view of
permitting the serum gradually to escape into the superficial cellular
tissue ; so converting the dropsy into diffuse oedema. Lately, it has
been proposed to treat the part as if it Ave re a hydrocele ; to draw off
the serum by tapping, and subsequently to inject a solution of iodide.
The practice seems much more likely to effect disorganization of a joint
than its cure. And, until ample experience shall have declared it a
safe procedure, we shall hold such tamperings with the larger articu-
lations—the knee, be it remembered, is the most frequent scat of the
disease—to be in the highest degree rash and umvarrantable.
2. Scrofulous Clironic Synovitis.—This affection is accompanied with
marked indications of the strumous cachexy, throughout its whole
course, as Avell as previous to its accession. The membrane slowly
and silently degenerates into a gelatinous pulpy substance, soft, and of
a Avhitish or light gray colour; at first with merely an exaggeration of
the ordinary secretion, slightly perA'erted in character—thicker and
more opaque. But suppuration is not unlikely to folloAV, probably
occasioned by acute inflammatory accession ; or, it may be, merely in
accordance with the omvard progress of the original disease. From
Avhatever cause induced, the occurrence is quickly folloAved, as usual,
by great aggravation of the symptoms, both general and local, and
speedy disorganizing involvement of both cartilage and bone.
This is an affection altogether different from the broAvn and dense
degeneration of the synovial apparatus; the one is simple, and com-
paratively tractable; the other is suspected of malignant tendency, and
is but little obedient to any remedial treatment,
The symptoms differ from those of ordinary synovitis. The patients
are usually adolescents, and evince more or less strongly the scrofulous
cachexy. A slight injury, as a blow, strain, or twist, may or may not
have been sustained by the part. The joint slowly swells, and has its
motion more and more impaired; but little or no pain is experienced.
The swelling is soft, doughy, someAvhat elastic, but totally devoid of
any thing like true fluctuation ; the integuments are pale, and scarcely
tense ; and even free pressure and manipulation are comparatively well
borne. In this indolent condition, the joint may continue for months;
but, failing gradual cure, or approach thereto, suppuration usually
supervenes; an event, followed and characterized by the usual aggra-
vation of symptoms, both local and general.
During the progress of this disease—and indeed the observation may
be extended to almost all serious and chronic structural change of joints
—the Avhole limb undergoes an atrophy ; hard textures as well as soft.
The bones become more slender in their shafts, and of less density ; the
adipose tissues disappears by absorption; the muscles waste, grow
flabby, pale, and weak ; in the lower part of the limb passive conges-
tion and oedema are not unfrequent.
_ It may be here stated, also, that in many examples of diseased joints,
in whatever texture morbid action may have originated, the advanced
stage is often complicated by enlargement of the lymphatic glands;
sometimes indolent, sometimes active and prone to suppuration, in the
ON SCROFULOUS CHRONIC SYNOVITIS. 289
axilla, from diseased elbow, for example ; in the groin, from diseased
hip or knee. The complication is a serious one, and ought ahvays to
be taken into acccount in both treatment and prognosis.
Treatment.—In the early stage, the local treatment is the same as
for the simple chronic synovitis: rest and counter-irritation, the latter
preceded by very moderate depletion. Constitutionally, the ordinary
remedies are to be employed, Avhereby the system's taint may be most
hopefully opposed ; and this anti-strumous treatment must be maintained
unweariedly throughout. When the indolent condition has become
thoroughly declared, pressure and confinement from motion—so as both
to arouse absorption of the redundancies, and to permit of its advance
without interruption—constitute the principal remedial means.
Rest and pressure, indeed, arc poAverful agents of cure in all chronic
affections of joints, however originated ; AA'hether occurring in their hard
or soft tissues; but most hopeful in the latter case, as can readily be
imagined. And there is every reason to believe, that to the better con-
ducted, as Avell as more frequent use of them, the marked improvement in
the treatment of diseased joints in modern times is mainly to be attributed;
many an articulation is now saved, Avhich formerly would have been
unhesitatingly doomed to amputation. Much credit is due to Mr. Scott,
for having directed attention to the importance of rest and pressure,
combined with moderate irritation of the surface ; and a modification of
what is ordinarily termed " Scott's dressing," Avill be found a most
valuable remedy, in all chronic affections of joints, in the truly indo-
lent stage; more especially in those wherein the diseased action has
not only originated in the synovial apparatus, but is still limited to that
tissue. The limb having been uniformly supported by a bandage, from
its extremity up to the affected joint, the surface of the swelling is
covered by strips of lint, spread Avith some gently stimulating ointment
—soap cerate with camphor, for example, or that Avith a greater or less
proportion of the unguentum hydrargyri; the Avhole articulation is then
surrounded by long bands of "adhesive plaster, draAvn Avith moderate
and uniform tightness, so as to support and firmly yet uniformly com-
press the parts, without producing absolute pain or uneasiness. Above
all, splints are applied to secure total immunity of motion ; and they
may be of leather, of pasteboard, or of wood—the first usually the most
suitable. When this dressing has become loose, from subsidence of
the swelling—as usually hapens in a few days, when first employed,
progress thereafter becoming more gradual—it is reapplied, as often as
may be necessary. But should fresh excitement occur in the joint, from
any accidental cause, this system of dressing must be discontinued,
until such excitement has been subdued by the usual means ; and when
the pressure is resumed, it should at first be very moderate. Such acute
re-accessions are least likely to occur in the truly synovial affections.
During the treatment, the limb must be kept, or gradually brought into
the most advantageous position for future usefulness ; particularly, if,
from the nature, duration, and extent of the disease, there is reason to
suspect ultimate impairment of the joint's motion. Thus, by steady
extension with splints, the knee-joint may be brought into nearly a
straight position, so that it shall be serviceable m progression ; and the
290
PRINCIPLES OF SURGERY.
elbow may be bent, to form a right angle with the humerus, so as to
be convenient for prehension. By prudent yet persevering friction,
and occasional passive motion, these desirable changes may be greatly
facilitated. But all such alterations of stiffened limbs must be proceeded
with very cautiously, othenvise they may occasion undue excitement,
and consequent reneAval of the disease.
The Brown Intractable Degeneration of the Synovial Membrane.
The joint most frequently attacked by this formidable disease is the
knee ; and the usual patient, is the adult female. The synovial mem-
brane sloAvly and insidiously degenerates into a pulpy-looking substance,
altogether different from the preceding affection ; the mass is of darker
hue, and of greater thickness and extent; it is also of greater density,
and intersected by many firm, fibrous bands, someAvhat after the manner
of carcinoma. I am far from stating that the two diseases are identical;
but they certainly do resemble each other, as to the fibrous constituents,
in the apparent section ; and though the disease, now in question, can-
not be roundly termed truly malignant, yet most certainly is it but little
amenable to any remedial treatment, and very prone to assume, if it do
not originally possess, malignancy.
At first the external indications of the disease are similar to those
of the simple gelatinous degeneration ; a gradual, soft, comparatively
painless tumour of the joint, unaccompanied by superficial excitement.
Yet the SAvelling is more diffuse, and less prominent, as if indicating
that the diseased action had more securely and deeply fastened on the
whole extent of the joint; it is more decidedly elastic, often simulating
true fluctuation very closely ; it is of a uniform character, and has no
peculiar bulgings dependent on the natural form of the joint; the un-
easy sensations are greater, and obviously more on the increase—of a
deep gnaAving kind, gradually augmenting into smart lancinating pain;
there is an obvious concomitant cachexy, but quite different from the
scrofulous—rather like that which attends on malignant diseases—a
sallowness of hue, loss of strength, flesh, and spirits, and ultimately
gradual sinking in the form of a modified hectic.
It seldom if ever assumes the quiet indolent form so frequent in the
simple synovial degeneration. Only at its commencement is it slow
and latent. Once fairly established, it advances steadily, and some-
times with rapidity. Ultimately the joint is Avholly destroyed, in one
or two ways ; either by the ordinary inflammatory products, or by the
formation of a malignant tumour. In the former case, a suppurative
crisis takes place, as in the simple degeneration ; cartilages, bones,
ligamentous apparatus, are all quickly involved in ulceratiA'e destruc-
tion ; the joint opens, probably at several points; urgent hectic is
lighted up, and amputation is imperiously demanded; or the patient
may sink Avithout any opportunity having occurred for the trial of that
doubtful remedy. ^ In the latter case, there is no acute crisis, followed
by opening of the joint and its palpable disorganization ; but there is a
steady increase of both the general and local symptoms. The face gets
more and more thin and cadaverous, the frame wasted, and the vital
ON THE FIMBRIATED SYNOVIAL MEMBRANE. 291
power sunk. The tumour continues steadily to advance, and ultimately
it is observed that the rate of growth has plainly increased ; the surface
becomes tense, smooth, polished, and traversed by large veins ; pain is
more acute, constant, and lacinating; elasticity is more prominently
its characteristic than ever ; fluctuation may be suspected, and a plunge
made -by trochar or knife, but nothing escapes save blood, and that
copiously; in fact, the SAvelling has noAV truly become an encephaloid
formation. The disease began, intractable ; early, it shoAved a malig-
nant tendency ; ultimately it has openly assumed not only an avoAvedly
malignant action, but also the peculiar deposit of perhaps the most
malignant of all adventitious formations. This latter, hoAvever, is to
be considered only as an occasional result; the former—disorganization
by the ordinary inflammatory products—is certainly the more frequent.
Treatment.—This may be comprised in very feAv AA'ords. In the
early stage alone can Ave hope for an -altogether successful issue, and
this is to be sought for by the ordinary means ; rest, counter-irritation,
and attention to the general system. Even then, cure is far from cer-
tain ; nay, it will prove the exception rather than the general rule.
After the omvard progress has been fairly declared, the sooner amputa-
tion is performed the better ; a severe measure, doubtless, but fully
warranted by an experience of the general nature of the disease ; and a
measure towards which we should be all the more urgent, by reflecting
that if the medullary formation be once established—and it is at least
possible that such may be the impelling issue—even amputation may
prove at the best but a palliation; the general disorder continuing un-
abated, and hasting forward to a fatal and early termination.
The Fimbriated Synovial Membrane.
Of this comparatively rare affection, there are but few examples even
in our best appointed museums. " The synovial membrane may be
studded on its inner aspect with pendulous substances projecting into
the cavity of the joint; sometimes of almost cartilaginous consistence,
but more frequently of a fatty appearance. The entire surface of the
membrane is occasionally covered with these bodies, which are of a
white or yellowish colour, and very variable in size and shape ; the
smallest presenting the form of villi not much larger than those of the
jejunum, the largest having somewhat the magnitude and appearance
of the appendices epiploicae of the large intestine, while many of an
intermediate size approach in appearance to a lemon seed. In some
instances the membrane is only partially pervaded by them, and some-
times they are arranged like a fringe around the edge of the articu-
lation. They are generally very smooth on the surface, Avhich appears
to be perfectly continuous, if not identical, with the synovial membrane.
Their attachment is sometimes broad, sometimes very narrow and
pedunculated, often merely filamentous ; so that a little farther thinning
of the part, or slight force acting on the body, would remove it from
the capsule, and "throw it loose into the cavity of the articulation.
The disease has been most frequently seen in the knee, and sometimes
in the elbow.
292
PRINCIPLES OF SURGERY.
" The affection is obscure in its nature, and sIoav in its progress ; the
joint is the seat of pain after and during the exercise, probably from the
anormal processes interfering with the motions of the articular surfaces.
As the disease advances, the joint becomes swelled and elastic, unat-
tended generally by ulceration of the tissues Avithin or around it. In
examining the part, when the articular surfaces are moved on each
other, it will be found that their motion is more or less interfered with;
and considerable irregularity in their action may be felt by the hand
placed firmly on the joint during the procedure."*
The same treatment is required, as for the ordinary synovial derange-
ment, of the most chronic form.
Tlie Inflammatory Process in the Exterior of Joints.
This may be of the simple and ordinary kind ; and then prone to
suppuration. Or it may be of an obviously rheumatic character; tending
rather to chronic change of structure.
1. Rheumatic.—When acute, it is usually merged in a deeper and
more important affection ; it may originate exteriorly to the joint, but
this sooner or later is involved, usually at a very early period ; and the
case may then be considered as one truly of rheumatic synovitis. But
the chronic form very frequently is not only originally, but perma-
nently, Avholly exterior to the articulation ; or if the latter do sympa-
thize, it is only in a very minor grade of action, barely sufficient to
increase slightly the natural exhalation of the part—not greater sym-
pathy than the exterior often shows in the less serious inflammatory
affections of the joint.
The inflammatory process is of a low grade, and chronic in its na-
ture ; situated either in the periosteal investment of the articulating
extremities of the bones, in the fibrous tissues exterior to the joint, or in
both. The periosteum thickens, and becomes vascular; the correspond-
ing surface of the bone, sympathizing fully in the action, opens out in
texture, and becomes studded by osseous nodules, sometimes shooting
outAvards in a spiculated form ; and this neAV osseous formation may,
by encroaching on the joint, come seriously to impair its poAver of
motion, or even ultimately to cause complete stiffness by an external
true anchylosis. The ligamentous and other fibrous tissues undergo a
someAvhat similar change ; they increase in bulk and in vascularity;
more or less plastic matter is interstitially exuded, and, becoming orga-
nized, seriously impedes motion, and may result in more or less com-
plete rigidity. All this is attended by the ordinary rheumatic symptoms;
more especially, by pain, often severe, aggravated nocturnally and by
atmospheric exposure or vicissitude ; swelling, deep-seated, and hard,
painful on pressure, and not unfrequently somewhat masked by super-
ficial oedema ; a stiffness and crankiness of motion in the joint gradually
increasing; and rheumatic signs not Avanting in perhaps many other
parts of the frame.
There are plainly tAvo dangers to be dreaded from continuance of
* Liston's Elements of fe'urgery.
TOPHI.
293
such an affection ; inflammatory accession, involving the joint in acute
synovitis : and persistence of the original malady, slowly yet surely
compromising the function of the part. On both counts, therefore, it
is our duty to cope zealously Avith the malady, at an early period.
Locally, by the ordinary antiphlogistics ; especially leeching, or cupping
in the vicinity, fomentation, rest, and, if need be, counter-irritation.
Constitutionally, by the exhibition of colchicum, iodide of potassium, or
other remedies held as suitable opponents of the rheumatic diathesis.
2. Simple.—The inflammatory process occurring in the parts imme-
diately exterior to a joint, unconnected Avith any peculiar condition of
system, is usually acute, and tends towards the suppurative crisis. It
may be the consequence of external injury ; or it may be but a part of
a more extensive disorder—as erysipelas. Or the affection may be.
idiopathic, and chronic in its nature; consisting first of a fibrinous
exudation, causing hard swelling with stiffness of the joint, dull ancl
indolent; and after months passed in this type, then assuming the sup-
purative action. However occasioned, the suppuration folloAvs the
usual course, and the matter seeks the surface. If opposed in that
direction—as it is certain to be, if originating among and not exterior
to the fibrinous tissues—it cannot but extend both laterally and in
depth ; so, obviously and imminently, endangering the articulation. If
purulent irruption take plaCe there, it will be hard to prevent the imme-
diate invasion of such an inflammatory action as shall result in destruc-
tion of all the component textures, as well in the establishment of the
most violent and alarming constitutional disturbance.
The treatment, therefore, must be both early, and actively antiphlo-
gistic ; in order to arrest the inflammatory process, if possible, ere the
suppurative crisis shall have been attained. When this has occurred,
an incision can scarcely be made too early, free and dependent, in
order to avert the articular irruption. In either case, the most rigid
rest of the part is to be maintained, and the constitutional symptoms
are subdued by the suitable remedies.
Tophi.
These are concretions connected with the extreme articulations, more
particularly of the fingers ; sometimes within the joint, more frequently
exterior to it—at least in the first instance ; and are composed of the
urate of soda. They are undoubtedly connected with, and probably
owe their origin to the gouty and rheumatic diathesis, especially the
latter. They may remain in an inactive state, either stationary or
gradually enlarging, for a long period ; or imperfect suppuration may
occur on the surface, opening the skin, and disclosing the concrete
matter slowly disintegrating, and crumbling tardily away with the
thin puriform discharge ; and this may be accompanied with some pain,
and redness and swelling of the surrounding integument. Or a chronic
and imperfect suppuration and softening may pervade the whole mass,
instead of being limited to the surface ; this, however, is a compara-
tively harmless event, seeing that the proper texture of the joint has
been previously annihilated by gradual structural change, antecedent
25*
294
PRINCIPLES OF SURGERY.
to the peculiar deposit, or at least co-existent with it; what was the
joint may be opened into, but the circumstances will not be marked by
any of those serious consequences Avhich Avould be certain to accrue
did any form of the synovial apparatus remain.
Such concretions, Avhen fairly formed, are plainly but little amena-
ble to local treatment. The great object is to prevent their formation;
by constitutional management directed against their cause, the gouty
or rheumatic diathesis. And, according to late chemical disclosures,
an important auxiliary has appeared to the ordinary remedies in vogue ;
namely, the benzoic acid ; Avhich, given in full doses after meals, is
said to have the effect of converting the uric into the hippuric acid.
and consequently the comparatively insoluble urates into the hippu-
rates—comparatively soluble.
Destruction of Cartilage.
This may be either simple or scrofulous. It may be the result of
absorption, ulceration, or local death ; ulceration is by far the most
frequent agent of removal. Sometimes all these are combined; fol-
lowing the order, as to time of operation, in Avhich they are here stated.
The morbid action may originate in the cartilage ; then it is usually
quiet, insidious, and sIoav in its first progress. Or the affections of that
tissue may be altogether secondary ; the result either of advanced syno-
vitis, or of structural change proceeding from the cancellated texture
of the articulating extremities of the bones ; in either of such cases, the
cartilaginous invasion is rapid and acute.
I. Simple destruction of Cartilage.—When original, this is
almost invariably a leisurely process ; and it may be conveniently
divided into stages. 1. The texture becomes vascularized. There
seems little doubt that the articular cartilage, in its normal state, is non-
vascular. But to its undergoing the ordinary morbid processes, espe-
cially that of ulceration, it is natural to suppose that its permeation by
blood-vessels is essential; and it has long been understood that vascu-
larization accordingly does occur, as a preliminary and indispensable
change. What Avas matter of inference, has lately been made'rmitter
of demonstration, beautifully illustrated by injection of the morbid tissue,
by Mr Liston.* This vascularization is to be regarded as the result of
simply perverted nutrition, or the inflammatory process in its very
lowest and primitive grade ; causing softening and enlargement of the
tissue, and attended with but slight feelings of uneasiness. 2. "While
vascularization is being accomplished, or speedily after its attainment,
interstitial absorption is in progress. By this the cartilage—soft and
tumid from the process of vascularization—is sometimes thinned, but
more frequently only opened up in texture ; and, as it were, rendered
a suitable and unresisting victim to the coming ulceration. 3. Con-
tinuous absorption may now occur, and frequently does, causing loss
of substance ; usually commencing on the free surface of the cartilage;
and unattended by any purulent or even puriform secretion. 4. The
Medico-Chirurgical Transactions.
ON DESTRUCTION OF CARTILAGE.
295
foregoing state of matters may exist for weeks, or even months ; weeks,
however, or days, being usually the more suitable for computation.
Then true inflammation becomes established. Ulceration ensues ; ren-
dering loss of substance more direct and rapid ; attended with purulent
secretion, more or less profuse—noAV occurring for the first time ; and
accompanied by marked accession of pain, and other ordinary signs of
the inflammatory crisis. The ulceration may either partake of the
chronic nature Avhich has hitherto characterized the morbid process,
extending sloAvly ; and, even after some considerable time, producing
an ulcer, or ulcers, of but limited dimensions, the major part of the
tissue remaining entire. Or it may assume an acute character, and
speedily involve the Avhole, or greater part in destruction.
The vascularization may be begun by the investing synovial mem-
brane, by the subjacent bone or by both. And these originally vas-
cular textures, as a preparatory step, themselves undergo the chronic
and minor grade of the inflammatory process ; becoming thereby slightly
tumid, and considerably increased in vascularity. According as either
is the main agent in the initiatory change of the cartilage, so it is pro-
bable that on the corresponding aspect of that tissue the absorptive and
ulcerative loss of substance will be begun ; the ulcer advancing either
from the surface toAvards the subjacent bone, or in the opposite direc-
tion. The former is the more common course ; whence we would infer
that the synovial membrane—changed at that part by increased vascu-
larization, apparently on very purpose—is the chief agent in the de-
struction of the cartilage. And, even Avhen the progress has been from
beneath, there is little doubt that sIoav vascularization and turgescence
of the synovial membrane are of early occurrence ; so that when the
true inflammation has been established in the hard articulating tex-
tures, the soft are abundantly ripe for sharing therein.
The characters of the ulcer may vary according to its extent. When
limited, it is often of a circular form, and seeming as if a chemical
erosion of the tissue had there occurred ; Avithout any sign of attempted
repair. When the tissue has been perforated, the subjacent bone is
exposed ; and the characters are those of ulcerated bone surrounded by
irregularly disposed cartilage. The synovial membrane, in the imme-
diate vicinity, is red, SAVoln, and pulpy ; plainly undergoing inflamma-
tory change of structure. The parts most prone so to suffer, are those
most liable to pressure—for example, on the inside of thejiead of the
tibia, and the corresponding points of the condyles of the femur.
Healing may occur in different Avays. 1. In the superficial and
limited forms, there is an effusion of plasma, on subsidence of the
ulceratiw and inflammatory action ; mainly contributed, it is probable,
by the synovial membrane. This plasma becomes organized ; forming
a dense adventitious texture, not cartilaginous, Avhich partially fills up
the chasm ; at the same time, by absorption of the margins, a smoothing
or bevelling process is effected ; and the neAV substance then becomes
incorporated and continuous with the surrounding synovial membrane.
A dense, firm, depressed cicatrix, with smooth and sloping margins, is
thus produced. There is no reproduction of the cartilage. 2. When
296
PRINCIPLES OF SURGERY.
the ulcer has penetrated to the bone, and also perhaps involved that
texture someAvhat, a similar cicatrix results; but with this difference,
that the neAV matter is not furnished by the soft textures but mainly by
the hard. The bone then throws out plasma ; osseous nodules result
therefrom, and occupy the exposed surface of the bone. These do not
rise to fill the chasm, but remain limited and low, becoming smooth and
rounded off on their surface. Exterior to this neAV osseous layer, there
may or may not be a plasma from the synovial tissue, becoming organ-
ized, and, constituting the medium of incorporation betAveen the hard
and soft parts. 3. Or there may be no depression of the cicatrix, and
no investment of it by adventitious soft texture. The exposed bone
may furnish a greater amount of neAV matter, Avhich attains to' a higher
level, than in the former case ; at the same time the surrounding
cartilage becomes attenuated by absorption ; in consequence, the new
osseous formation comes to be on a level with the surrounding surface,
and there groAvs dense and compact. There is no investment of this
by reproduction of synovial or other soft texture ; itself has to bear the
friction of the opposed surface, on resumption of function ; and, as if in
order to be able to discharge that duty to the utmost of its ability, it
becomes unusually dense and smooth on the surface, by deposit of
earthy matter of a peculiar kind, termed porcellanous—the surface,
which is thereby formed, proving smooth and fine as that of porcelain.
This is doubtless inferior to the elasticity of cartilage, and the lubricity
of its investing synovial membrane, but yet is a Avonderfully efficient
substitute. 4. Or the healing process may yet be of a fourth kind.
Often deep ulcers of cartilage exist at opposite and corresponding points
of the articulation. From these, osseous reproductions, springing up,
are not unlikely to coalesce, causing fixity of the joint by anchylosis.
Sometimes death of cartilage, in continuous mass, complicates and
aggravates the process of ulceration. In such cases, doubtless, the
initiative has been in the subjacent bone ; ulceration has thence begun
on the deeper part of the cartilage, and may have extended much more
in a horizontal than in a vertical direction. Thus a portion of the car-
tilage becomes attenuated and undermined ; and, folloAving a like course
with skin, or any other texture similarly circumstanced, dies. By con-
tinuance of the ulceration, the dead portion is ultimately detached;
and, becoming loose in the joint, adds, to the mischief already there,
Avhat is sure to result from the presence of extraneous matter within an
inflamed synovial cavity.
The symptoms of such change of structure in articular cartilage are
very distinct from those of affection of the synovial membrane. With
ordinary care, they need never be confounded. As already stated, in
the advanced stage of joint disease, Avhen all textures are involved,
there is no means of ascertaining by present symptoms the original and
chief seat of the malady ; but Avhile the morbid action is advancing in
one texture, and as yet limited to that, the diagnostic signs of its
presence and nature are usually plain enough. Be it remembered,
however, that the symptoms of ulceration of cartilage, although inva-
riably indicative of that affection, are not ahvays indicative of its
ON DESTRUCTION OF CARTILAGE.
297
amount, because not uniformly proportioned thereto. Sometimes we
find much greater annoyance, both constitutionally and locally, from a
single small erosion, than from a Avide expanse of destruction.
The symptoms are found to tally Avell Avith the claim of pathological
events formerly stated. At first there is dull and deep uneasiness in
the part, with some impairment of motion ; but Avithout swelling or
other apparent change of structure. This state may continue for days,
or even Aveeks, with but little change ; it corresponds to the period of
vascularization and commencement of absorption. The uneasy feelings
become more marked, and are aggravated nocturnally ; absorption,
both interstitial and continuous, is in progress. The pain is undoubted ;
deep, constant, Avorse at night; usually referred by the patient to one
particular spot deep in the joint, and likened by him to the unceasing
gnawing of an animal there. This is the period Avhen absorption is
becoming, or has become, superseded by true ulceration. Acute pain
comes Avith the advance of the inflammatory process towards its crisis,
and keeps pace with it. It is aggravated by motion, more especially
if great and sudden ; and, on gentle movement of the part, a grating
sensation is ultimately perceived, in consequence of exposure of op-
posing points of bone. Very frequently there is a sympathetic pain
complained of, sometimes fully as much as that in the part—an example
of irritation in one part, induced by inflammatory change of structure
in another. Pain in the knee, for example, is usually the most promi-
nent symptom of disease in the hip ; pain in the leg, may mask ulcera-
tion of the cartilages in the knee. The Avhole of the limb beneath the
affected joint is usually both functionally and vitally Aveak ; feeble and
tottering; of diminished temperature, and inclined to oedema.
Wasting of super-imposed muscle is often both a prominent and early
symptom of articular disease ; atrophy of the deltoid, for example, may
be the first to betoken ulceration of cartilage, of bones, or of both, in
the shoulder; and flaccidity of the glutei does the same in regard to
morbus coxarius. In the child, however, we must be on our guard
against mistake on this point; inasmuch as muscular atrophy not un-
frequently occurs, in early life, altogether unconnected with articular
disease ; dependent on dentition, or on intestinal irritation.
Swelling does not appear till uneasy sensations have been present in
the joint for three or four Avoeks, it may be for months. It folloAvs the
steady aggravation of pain Avhich indicates the advance of the inflam-
matory process, and its approach toAvards true ulceration ; and is both
less bulky, and less rapid in its formation, than that Avhich attends on
synovitis. It is composed of tAvo parts ; one internal, caused by gra-
dual distention of the synovial pouch by slowly accumulating pus, now
for the first time begun to be secreted; another external, by interstitial
effusion in the textures exterior to the joint, these being iioay_ involved
in a tolerably active sympathetic action. In consequence of its double
and gradual nature, the peculiar bulgings dependent on the natural
conformation of the joint do not occur ; a diagnostic mark betAveen this
affection and chronic synovitis. In acute synovitis, swelling is tole-
rably uniform ; but at the same time it is great, rapid, and coeval with
the occurrence of pain ; whereas in ulceration of cartilage, it is sIoav,
298
PRINCIPLES OF SURGERY.
gradual, never great, and long subsequent to the feeling of uneasiness
in the part. In chronic degeneration of the synovial membrane, on the
other hand, the SAvelling is slow, and someAvhat uniform, like that of
ulceration ; but still it is coeval Avith uneasiness, and elastic, doughy,
and superficial—not deep and obscurely fluctuating, like that of ulcera-
tion. The latter SAvelling too, is intolerant of pressure, pain being
thereby much increased ; the other, on the contrary, is capable of bear-
ing manipulation with comparative impunity.
After the swelling has become fully established, the inflammatory
action is seldom long limited to the cartilage, but involves all textures.
Pus accumulates; deposit and change of structure take place in the
synovial membrane and textures exterior ; ultimately, by ulceration
there, the fluid escapes from the joint, makes its Avay to the surface, and
is thence discharged; not Avithout loss of substance in the ligamentous
texture, as Avell as relaxation of that Avhich retains its integrity, causing
extreme laxity of the articulation. In consequence of this laxity, the
joint, Avhich previously had assumed the position of semiflexion, as in
affection of the synovial membrane, may become Avholly luxated; the
flexor muscles having then to encounter but little opposition to their
displacing force; and ordinarily there is also more or less rotation, or
other displacement, one muscle, or set of muscles, exerting a supremacy
of poAver. Thus, in such affection of the knee, the bones of the leg are
dislocated backAvards into the popliteal space ; and at the same time
the head of the tibia is usually rotated outwards, by the preponderating
action of the biceps flexor cruris.
Such important local changes are not unattended with sympathy of
the system. At first the general symptoms are but slight; little more
than general discomfort, or slight feverishness, being complained of.
But Avhen pain becomes undoubted and steadily crescent, inflammatory
fever is declared Avith more or less intensity ; usually accompanied by
involuntary startings of the affected limb—especially during sleep—by
the jarring and motion of Avhich, pain is fearfully aggravated, and the
inflammatory action hurried on its destructive tendency. Ultimately,
in the open, lax, discharging, perhaps dislocated state of the part, hec-
tic is inevitable.
The results are various. Resolution may occur, ere ulceration has
been reached ; absorption alone having folloAved on the vascularization,
and having given Avay to rest and counter-irritation. Or the ulceration,
having occurred, may prove but slight and transient, and function be
restored ; the breach being closed in one or other of the ways already
noticed, and the trifling purulent secretion, Avith ulcerative debris,
having been absorbed. Or osseous reproduction may prove excessive,
occasioning true anchylosis ; the limb being retained, but permanently
maimed in the function of its articulation. Or the inflammatory de-
struction may ultimately become both so general and so great, and the
constitutional sympathy so formidable, as to banish all hope of saving
the part, even with impaired form and function ; compelling us to direct
our attention solely to the saving of life, by dooming the member to
early amputation.
The affection may be idiopathic. More frequently it is attributed to
ON DESTRUCTION OF CARTILAGE.
299
external injury ; perhaps slight; probably neglected. Exposure to cold,
too, is favorable to its induction ; as are both the mercurial and syphi-
litic taints of system. It is more frequent in the adult, than at an
early age.
Treatment—-The obtaining of a complete immunity from all motion,
by the adaptation of splints, is the paramount indication from the be-
ginning to the end of the period of cure. Local depletion is had re-
course to; partly on its oavh account, but chiefly as preparatory to
counter-irritation, which is doubtless entitled to the first place among
the directly remedial agents. The vesicant form of counter-irritation,
we found to be most suitable for affections of the synovial membrane. ~
In this disease, a higher grade, the pyogenic, is required. Issues are
the form generally in use ; and they may be established by either the
potential or the actual cautery ; the former is in the greater number of
cases equally effectual as the latter, and, being the milder in applica-
tion, is therefore to be preferred. But in the larger joints, and in others
where mild means have already been ineffectually used, let the graver
remedy be certainly employed. The cure is invariably tedious; and,
consequently, the counter-irritation, with other means tending to its
attainment, require to be patiently continued. It is not enough to
establish an issue, and then leave it to heal or not according to circum-
stances. For some time, often considerable, the irritation and discharge
must be continued from the surface ; and this may be effected in one
of two ways, either by forming a succession of fresh issues, or by main-
taining an open state of the one originally made. The latter method is
most commonly followed ; equally effectually as the other, less trouble-
some to the surgeon, less painful to the patient. The discharging sur-
face is dressed from time to time with some irritating ointment or lotion,
as the savine, tartar emetic, &c.; or it may be retouched occasionally
by the potass or other caustic. This last mode of refreshing the sore
is probably the best; the inflammatory re-accessions, thereby induced
in the surface, being of service, as well as the maintenance of sufficient
purulent discharge ; it is generally our object not to obtain either counter-
irritation or evacuation alone, in these cases, but a combination of both.
Also, let us at all times beware of placing the artificial sore too near
the joint; otherwise we shall fail in counter-irritation, and apply a
direct stimulus to the morbid action. Constitutional treatment is at the
same time conducted, according as circumstances may demand; at
first antiphlogistic, afterwards cautiously roborant. When, in the early
stage, much pain and spasm exist, full opiates are indispensable; as
the continuance of either must inevitably lead to aggravation of the
disease.
In the more favourable cases, such treatment is slowly followed by
gradual amendment; the pain abates, and ultimately ceases ; the con-
stitutional symptoms also disappear ; SAvelling yet remains, but softer,
indolent, and infinitely less painful, even on pressure. When this state
of quiescence has been reached—action having ceased, and its results
merely remaining—the counter-irritation is to be desisted from. The
issues are allowed to heal; the splints are retained, still to control
motion; and pressure by the method formerly mentioned, is had r~
300
PRINCIPLES OF SURGERV.
course to, in order to hasten absorption of deposit, and consequent re-
turn to the normal state. At first, however, pressure must be applied
with especial caution, lest accession ensue ; and if this threaten, the
original treatment must be at once rencAved. When not only action,
but its products also, have been removed, motion is restored ; but not
till then ; passive at first, gentle, and brief; at once desisted from on
the occurrence of serious and continued pain. A certain degree of un-
easiness invariably attends on resumption of motion, however cautiously
conducted ; but that is not to deter from perseverance in its use. Only
when the sensation is that of undoubted pain, deep and constant as
before, not in any marked degree diminishing on cessation of the mo-
tion, are Ave Avarned of danger from premature employment of the last
item in the cure ; and such Avarning, at all times sufficiently plain, avo
are never to neglect. The splints are again resumed ; as well as leechen
and counter-irritation if need be ; and all movement is as scrupulously
avoided as before; otherwise back will come the ravages of renewed
disease, perhaps in an aggravated form. Such intercurrent inflamma-
tory accessions are by no means unfrequent; and not always the result
of malapraxis. They sometimes supervene on the quiescent state -of
the joint, Avithout any assignable cause ; but however induced, they aro
invariably to be met by a corresponding vigilance and propriety of
treatment.
In the open condition of the ulcerated joint, cure is by no means
hopeless. The probability is that motion will be permanently impaired
to a certain extent; but Ave have usually good hope of retaining the
part; amputation, now-a-days, is not the rule but the exception, even
in this class of cases. After the establishment of the open state, not
unfrequently the morbid action advances with increased virulence for
a time, as formerly stated ; and this exacerbation, expected, is to bo
met and subdued in the ordinary Avay. Aftenvards, by rest, constitu-
tional treatment, and, if necessary, counter-irritation—in addition to the
evacuant remedy Avhich has spontaneously formed—the quiet condition
is attained. And then the treatment by compression will often be fol-
lowed by the happiest results ; subsidence of swelling, gradual disap-
pearance of all uneasy sensations, closure of the apertures, and diminu-
tion of the discharge. The compressing apparatus is applied in the
ordinary Avay ; and does not require unusual frequency of reneAval, the
discharge in the truly quiet condition of the joint—to which state alone
such treatment is applicable—being inconsiderable, and not tending to
accumulate beneath the dressing, injuriously. Under such circum-
stances, however, it is expedient to abstract all mercurial ingredients
from the ointment and plaster, othenvise a constitutional influence may
be induced unnecessarily by that mineral ; the open state of the part
being most favourable to absorption. After satisfactory amendment
under the compressing plan, motion is to be cautiously attempted. In
some cases, Ave may succeed in restoring it completely ; in others, it is
incomplete, stiffening being to a certain extent insuperable, partly from
alteration in the joint itself, partly from structural change in the liga-
mentous and other apparatus exterior ; in not a few, motion is scarcely
if at all resumed, true anchylosis having occurred.
ON DESTRUCTION OF CARTILAGE.
301
In some cases—but much more seldom than in the scrofulous destruc-
tion of cartilage and subjacent bone—there is no hope of cure, even by
anchylosis. The disease will, as it were, accept of no compromise, but
insists on complete disorganization of every texture. If the part be
accessible—as the knee—it is to be removed by amputation, ere yet
the systein have been irretrievably involved in the doAvmvard progress ;
if inaccessible—as the hip—we can then only palliate what Ave cannot
cure. The constitutional symptoms are to be subdued by the ordinary
means. Locally, counter-irritation, as Avell as depletion, is not to be
thought of; but rest is all-important. By the skilful adaptation of
sjplints, so as to secure immunity from motion, yet Avithout galling the
part or annoying the patient, and not interfering Avith facility of dressing
requisite for cleanliness, much amelioration is obtained. Life is not
only made infinitely more tolerable, but may be protracted for even a
considerable period. Even in the most hopeless cases, decided benefit
will not fail to show itself; and in some, at first apparently irremediable,
the amendment may be both so marked and so sustained, as not only to
warrant the entertainment of a hope of cure, but even to carry that out
to a tolerably successful issue ; the joint may dry, and stiffen, and be
consolidated—both life and limb retained.
In any case of urgency, Avhose circumstances point to early amputa-
tion, it behooves us to consider, before determining on that extreme
measure, that it is possible the counter-irritant treatment may have been
carried too far, and that this may be the cause, at least in part, of both
the local and constitutional aggravation. Acordingly it is expedient,
in the first instance, Avhenever circumstances permit, to abandon all
active treatment—allowing the issues to heal, and maintaining absolute
rest of the part with due regard to the system—and to let an interval of
repose declare Avhether the urgency has arisen from the progress of the
disease, or from excessive action of the means of cure—intended coun-
ter-irritation having proved directly irritant to both part and system. If
the issues have been in fault, the symptoms will satisfactorily subside,
during this interval; amputation, in consequence, is not only deferred,
but may be rendered altogether unnecessary. If, on the other hand, no
amendment folloAV the cessation of active treatment, amputation is
unhesitatingly performed.
In those cases, in Avhich cure is slowly advancing by anchylosis, it is
very important, Avith a vieAv to the future usefulness of the limb, to have
regard to the position of the joint. In the elbow, for example, Ave will
prefer neither complete extension nor extreme flexion, but an interme-
diate rectangular position ; the limb, Avhen so fixed, being most favour-
ably disposed for prehension. The spontaneous flexion of the knee,
on the contrary, Avill be gradually undone, and yet full extension not
desired; the limb, Avhen slightly bent, so as to permit the Aveight to
rest on the ball of the foot, being the posture most suited for progression.
When cure has resulted, Avith fixity of the joint, Avhether in a favour-
able position or otherwise, a question arises as to the propriety of
attempting to overcome the rigidity and restore motion. When anchy-
losis is osseous and complete, the question may be unhesitatingly
answered in the negative. Disruption of the osseous interlacement
26
302
PRINCIPLES OF SURGERY.
could only be effected by violence, such as inevitably to induce inflam-
matory action, probably of a grave kind, in a part whose power of con-
trol has been greatly impaired by previous and recent disease ; the pro-
cess of disorganization advances aneAv, and the joint is lost. When,
hoAvever, the anchylosis is spurious, dependent on structural change in
the soft parts exterior to the joint, restoration of function is to be
attempted cautiously, yet with determination, by the ordinary means—
to be considered, Avhen treating of anchylosis.
True anchylosis having been undeniably and hopelessly established,
still a question may arise, Avhether or not the part is beyond the reach of
our remedial art. The original joint being thoroughly obliterated, and
all the textures enjoying a complete immunity from perverted vascular
action, may not an incision be made immediately beneath the stiffened
joint, the bone be there saAvn across, and the case subsequently treated
so as to establish there a false articulation—inferior doubtless to the
original, yet still capable of assuming at least some of its functions and
utility ? This has been practised by Mr. Barton of America, with suc-
cess ; section of the neck of the femur having been made in a case of
anchylosis of the hip-joint. But further experience is yet required, ere
such procedure can be said to be expedient in practice as feasible in
theory. And even supposing that its general safeness shall have been
established, it Avould yet remain obvious that all joints are not amenable
to the experiment.
Acute Ulceration of Articular Cartilage may be either original or
secondary, as to texture. That is, it may either be an accession on the
more common chronic form, originating in the cartilage itself, by the
slow and gradual process just detailed ; or it may follow on disease of
the synovial apparatus, the cartilage having been in the first instance
altogether unimplicated in the morbid action. In the latter case it is
probable that, during the progress of the synovial disease, the cartilage
has been sympathizing to such an extent, as to favour the occurrence
of its vascularization ; and that so a predisposition to the assumption of
morbid action is established in the previously non-vascular tissue.
Then, suppuration having occurred within the joint, by the advance of
the synovial affection, we can readily understand how ulceration of the
cartilage should follow ; pressure by the accumulating pus then acting on
a part, Avhich is both capable of, and predisposed to obey excitement to,
acute vascular action. The ulceration that follows is usually both acute
and extensive ; not unfrequently accompanied with partial death of the
cartilage ; this aggravating all the symptoms, and accelerating the joint's
disorganization. It may be, that after evacuation of the purulent
formation, in the open state of the joint, all action in time subsides ; the
secondary affection of cartilage and bone may then abate, as well as
the primary disease of the soft parts ; and hopes of cure may be reason-
ably entertained. But it is plain that cure, under such circumstances,
can be only imperfect—by anchylosis ; the ulceration having been both
too wide and too deep to admit of simple cicatrization.
Could we always be certain of the signs of acute suppuration in
synovial affections, an early incision might often arrest, or at all events
greatly limit, secondary acute ulceration of cartilage. But, unfor-
ON SCROFULOUS ULCERATION OF ARTICULAR CARTILAGE. 303
tunately, we are seldom satisfied of our diagnosis, until some time after
the event; when the matter has collected in considerable quantity, and
Ls already approaching the surface with a view towards its own evacua-
tion. Our duty then is to evacuate; to soothe the excitement which
will necessarily follow the wound, by rest, and by antiphlogistics pro-
portioned to the exigencies of the case ; and by subsequent continuance
of rest, and employment of the higher grades of counter-irritation, to
endeavour to arrest the ulceration Avhich Ave have not been able to
jx'_Scrofulous Ulceration of Articular Cartilage. —This
may originate in one of two ways. It may follow on the chronic gela-
tinous degeneration of the synovial membrane. Or it may be the result
of scrofulous disease in the cancellated texture of the articulating ex-
tremities of the bones; at first-chronic ; ultimately acute and rapid in
its destructive progress. The latter is the more frequent, and by far
the more formidable affection.
In the former case, there are at first the ordinary symptoms of the
indolent scrofulous degeneration. Then pain, deep-seated and severe,
supervenes; the constitution seems inclined to assume a more intense
and sthenic form of sympathy than before ; the swelling increases, and
there are undoubted "'signs of roused activity in the part. Ultimately
the swelling groAVS fluctuating, denoting that pus has formed in the
joint; this seeks the surface, and is discharged ; and then the work of
disorganization is likely to advance, till all the textures have been
irreparably involved. In the advanced stage, the joint becomes pecu,
liarly lax; previously, it was rigid and comparatively motionless ; now
it may be moved freely in any direction, and that with comparatively
little pain; partly from destruction, partly from relaxation of the liga-
mentous and other textures exterior. Luxation consequently is not
unfrequent, in the end.
Or the indolent stage may continue, while yet the cartilage is exten-
sively removed ; this being effected, not by ulceration, but by absorp-
tion. True ulceration is, however, at all times prone to supervene-
perhaps under the influence of some trivial exciting cause, as a slight
blow or wrench—along with suppuration and its usual results.
When the morbid action originates in the cancellated texture of the
articulating extremities of the bones, there is usually a considerable
period of comparative repose. Tubercular deposit gradually occurs,
filling the cancclli; accompanied Avith dull aching m the part swelling,
and impairment of function. The bone at that part manifests enlarge-
ment; partly real, in consequence of a certain degree of expansion
induced by the tubercular infiltration ; chiefly apparent only on account
of the atrophied condition of the muscles and other soft parts To thus
condition the term « white swelling" may^ perhaps be most truly ap-
plied ; the joint being large, weak, and deformed ; and the skin some-
times showing large veins beneath, being stretched over the deep swell-
ing, of a pale whfte hue. The infiltration of the soft part exte or to
the joint is not by serum, but by solid fibrinous deposit; the resul of
chronic, not of acute sympathetic action ; he work not of da , hut of
weeks, perhaps of months. After this state has existed for some time
304
PRINCIPLES OF SURGERY.
—perhaps for months—exacerbation takes place ; pain is greater and
more constant; motion is denied ; SAvelling of the soft parts is greater,
and more apparently the result of an inflammatory process; sleep ig
disturbed, and the spasmodic twitchings threaten ; the constitutional
symptoms are aggravated, and for a time display the ordinary characters
of smart inflammatory fever—modified, it may be, by the previously
existing cachexy. The commencement of this -exacerbation is coeval
with suppurative disintegration of the tubercular deposit in the cancelli;
its crisis corresponds to purulent irruption into the cavity of the joint,
the matter having made its Avay thither by means of ulcerative destruc-
tion of intervening bone and its cartilage. Not unfrequently ne-
crosis is combined Avith the ulceration, and dead portions of the cancelli
lodge in the articulation. Then the ordinary ravages ensue; inflam-
mation, suppuration, and ulceration, beginning in the bone and car-
tilage, but forthwith invading every texture ; and usually destroying all,
with a rapidity proportioned to the diminished power of both part and
system.
Sometimes scrofulous disintegration of the articulating extremities
occurs, Avithout any apparent previous deposit of tubercular matter in
the cancelli. These often suppurate, crumble down; and the ill-
digested matter, mingled Avith the debris, makes its Avay, either exte-
riorly, to the surface, or into the joint—or in both directions—and the
usual train of symptoms ensue ; all announcing the scrofulous character
of the case, the scrofulous origin of the morbid action, and pointing to
the unfortunate issue Avhich such affections usually produce.
The joints most prone to suffer, are those in Avhich the cancellated
texture enters most copiously into the composition of the articulating
ends of the bones.
Either from the scrofulous destruction of cartilage, inasmuch as it
depends mainly on the vice of system, is liable not to remain limited to
the joint originally attacked ; but to affect several, either at once or in
succession. For a like reason, the disease is most frequently met with
during the period of adolescence.
Treatment.—Our principal object, in the early stage, is prevention.
In the case of the gelatinous degeneration, to affect arrest and resolu-
tion of the morbid process, ere the cartilage have been involved ; Avhen
its vascularization may have been begun, but Avhen as yet the truly
morbid process is only threatened. In the tubercular infiltration, to
preserve that in the crude state, and if possible to obtain its absorp-
tion ; averting the softening and suppurating process; or at all events
limiting and moderating it; and perhaps, should it occur, preventing
its invasion of the joint's interior. Rest, maintained by splints, abso-
lute, and constant; moderate local depletion ; counter-irritation, .of the
higher grade, patiently sustained, and cautiously conducted, as to time,
place, and mode, so as not to overact its part; judicious and persevering
employment of such remedies as are best adapted to overcome or pal-
liate the scrofulous diathesis :—these constitute the means of treatment.
When suppuration has occurred and ulceration become establishedj
the general principles of surgery are to be sustained. By timeous inci-
sion, the purulent fluid is to be effectually evacuated ; that we may if
ON SCROFULOUS ULCERATION OF ARTICULAR CARTILAGE. 305
possible limit Avhat we cannot avert. The subsequent symptoms are
to be palliated, by every means in our power, both general and local;
and cure by anchylosis hoped for.
In those cases, in which it is plain the part cannot be saved—and in
this, the scrofulous form of open joint, unfortunately these do not con-
stitute the minority—amputation is naturally looked to as the only
source of hope ; that by sacrifice of a part, a mutilated whole may still
be saved. But careful inquiry and reflection are necessary, ere this
resource can be duly determined on; othenvise it may happen, that
by removal of a part we do not succeed in preserving the whole, eAren
for a time, but on the contrary greatly accelerate its decay. It may be
that the frame is irrevocably the victim of the tubercular cachexy, and
doomed sooner or later to perish thereby; but for the time relieved or
sustained by the breaking out of a drain, or safety valve, in the sup-
purated scrofulous joint, Avhereby the injurious deposit is extruded, with
comparative impunity; exhausting the system in one sense, it is true,
and inducing marked hectic, under which vital poAver must ultimately
be prostrated; but still keeping back the more formidable obstacle to
life, of tuberculated deposit in an internal organ—lungs, liver, kidneys,
or all. Such deadly internal disease may be only threatened as yet;
then the open joint may delay its invasion. Or the phthisis may be
already plain ; still the local discharge, if free and constant, may mode-
rate or even stop its onward progress. Whereas, should amputation
be performed, and should the wound dry and heal; the probability—
nay, almost the certainty is, that the internal and more serious disorder
will sustain a mighty and altogether uncontrollable aggravation ; and,
inducing a far Avorse form of hectic, hurry the patient fast into the
grave. With the open joint, he might have lived for months, in com-
parative ease ; Avithout it—supposing the operation to be in all respects
locally successful—days, or Aveeks at most, will see his doom. Ere
amputation be definitely resolved on, therefore, let there be a careful
revieAV of the patient's past history and present circumstances ; let the
state of the internal organs—more especially the lungs—be diligently
inquired into ; and if these appear free from tubercular disease, as well
as from strong predisposition thereto, let the operation be undertaken,
hopeful of success ; but if, on the contrary, the internal organs be plainly
already involved, and that seriously, let us by all means refrain from
amputation, and content ourselves with palliation of the more distress-
ing and urgent symptoms. When there are strong marks of predispo-
sition, but yet no decided evidence of the internal disease, expediency
of operation is at all times doubtful; and the question can only be
rightly resolved by deliberate use of judgment and experience. When
amputation is performed, immediate union of the wound by adhesion is
plainly not desirable ; sudden drying up of the long-continued discharge
might seriously incommode the system ; we seek suppuration and granu-
lation, and, by that mode of healing, have a gradual transition to local
soundness.
In acute synovitis, we found that the free internal use of mercury,
so as to produce its constitutional effect, was in many cases advisable
in order to save texture. In decided simple ulceration of cartilage,
26*
306
PRINCIPLES OF SURGERY.
also—more especially of the acute kind, or tending to assume that cha-
racter—-its use may be expedient. But to this scrofulous degeneration
of cartilage and bone, Ave deem it Avholly inapplicable. The scro-
fulous system has no tolerance of the remedy ; attainment to the locally
beneficial effect is more than doubtful; and the unguarded attempt is
likely either to fail in its object altogether, or only to achieve it miper-
fectly, Avhile at the same time the system receives a severe injury,
perhaps irreparable.
Hypertrophy of Cartilage.
Articular cartilage, like cuticle, a non-vascular tissue, may become
preternaturally developed, either generally, or only at certain points.
The parts most prone to undergo this change, are those where pressure
is habitually the least; as on the patella. Whether this occurs by
increased nutrition on the part of the subjacent bone and investing
synovial membrane ; or Avhether the cartilage has become slowly vas-
cularized, and itself effects its OAvn hypertrophy—seems yet to be
uncertain. The free surface is often less smooth and polished than in
the normal state ; dull, and almost villous in its aspect. The affection
may occur at any age. The symptoms are obscure; dull uneasiness,
perhaps a very slight degree of SAvelling, impairment of motion, and a
feeling of weakness in the part. The treatment will consist of rest, the
minor forms of counter-irritation, and attention to the general health;
the iodide of potassium is likely to be of use, both externally and inter-
nally. Afterwards, friction, and support of the part by bandage, or by
the elastic yet close-fitting knee-cap, will be advisable.
Atrophy of Cartilage.
This occurs chiefly in the old, at the points habitually most com-
pressed ; and the aged Avho have led a laborious life, much in the erect
posture, are the most prone to suffer. The joints of the loAYer ex-
tremity, especially the knee on its inner part, are the most frequently
affected. Not unfrequently, rheumatism seems to be concerned in the
change. At first the cartilage seems to be opened up in texture, the
absorption being decidedly interstitial; afterwards the normal density
is resumed, but with diminished bulk. The cartilage may be merely
thinned, in stripes or patches, continuous or detached; or it may be
wholly removed, exposing the subjacent bone ; this latter tissue however
is usually entire, giving way neither by absorption nor by ulceration,
but tending, on the contrary, toAvards reparative action. The symp-
toms are, like those of the opposite condition, obscure ; rigidity, crack-
ling sensation and noise in attempted motion, rheumatic pains, ten-
dency to occasional puffiness by superficial oedema; inability long to
maintain the erect posture, and still less to bear any considerable
weight. The principal treatment will consist of kindness to old age;
local support by bandaging or knee-cap; and perhaps complete rest,
with light counter-irritation, for a time, should the symptoms prove
unusually urgent, and the inflammatory process threaten to supervene.
OSSEOUS DEPOSIT EXTERIOR TO THE ARTICULATION. 307
Long confinement and severe local remedies are inexpedient; for it is
not to be expected that the atrophy will be so arrested; and the gene-
ral health Avould surely suffer.
Porcellanous Deposit.
This may be the result of ulcer in the cartilage ; one mode of repara-
tion being by the aid of dense deposit, assuming a vivid polish, as
formerly explained. But more frequently it follows on the foregoing
affection, atrophy. The bone is exposed, by the gradual removal of
the super-imposed cartilage; and then, the absorbent action usually
ceasing, a restorative is begun. New cartilage cannot be produced,
but a very efficient substitute may; a texture not soft, elastic, and finely
lubricated ; but dense, smooth, and of the finest polish. In some cases,
the open areolated texture of the exposed bone is retained; as if this
had merely become so condensed and polished on its very surface, by
dint of pressure and friction ; but more frequently the existence of new
deposit is plainly evinced, by closure of the areolae, and the glistening
surface is presented compact and unbroken. Very frequently the
opposing porcellanous surfaces—as of the tibia and femur—fit into each
other by grooves and ridges ; and thus motion becomes not only crank
but limited. Deposit of osseous matter exterior to the joint is also not
uncommon ; another serious obstacle to function. Contrary to what
might be naturally inferred, the new formation is found to contain a
less proportion of earthy matter, than does the ordinary bone.
The symptoms are similar to those of the most usual cause—atrophy
of cartilage; with the addition, frequently, of a distinct grating and
jarring sensation, felt on sudden motion. The treatment is the same.
The rheumatic diathesis is often co-existent; and may fairly enough be
blamed, at least in part, for the occurrence of the change of structure.
Osseous Deposit Exterior to the Articulation.
This may be the result of rheumatism, affecting the part, more espe-
cially the periosteal investment of the articulating extremities of the
bones, as formerly described. Or it may, like the two last affections,
be rather the mere concomitant of old age ; analogous to the ossification
of cartilage, as in the ribs, and trachea. To the latter form, the hip-
joint is especially liable. The ligamentum labri cartilagineum becomes
ossified, deepening the acetabulum, locking the head of the bone, and
greatly limiting the movement of the articulation. Dislocation is ren-
dered impossible, Avithout giving way of the elevated brim of the aceta-
bulum ; but fracture of the neck of the femur—a more formidable ac-
cident—is on the contrary favoured. At the same time, the bone around
the acetabulum is often studded, more or less copiously, with osseous
nodules of recent formation. Such a state of matters is obviously not
amenable to treatment Avith the hope of cure. It is sufficient that the
duties of the part shall be made to correspond to its modified powers
of performance ; exposure to casualty by external violence being at all
times sedulously avoided.
308
PRINCIPLES OF SURGERY.
Interstitial Absorption of Bone, Implicating the Joint.
This also applies especially to the hip-joint. In consequence of
external violence, as a smart dIoav, or fall on the trochanter major, it is
not uncommon to find the neck of the femur undergo much change by
interstitial absorption. And similar alteration may occur, spontaneous-
ly ; that is, without any assignable cause ; seeming, like some of the
affections last noticed, to be one of the many signs of the frame's decay,
not only in mass, but in its details, Avhich usually accompany old age.
This idiopathic form is perhaps most frequent in women, the greater
length and rectangular position of that part of the skeleton in them,
seeming to predispose thereto. The neck of the bone is shortened;
the head approaching the trochanter, till at length it seems to be set on
there, without any intervening neck at all. At the same time, the an-
gle is changed ; the natural obliquity upwards becoming altered, first
towards the rectangular position, and ultimately the head of the bone
descending to form an angle of a precisely opposite kind. The degree
of shortening varies, from half an inch to two or even three inches;
and the lameness is in proportion.
The head of the bone itself usually undergoes some change, partly
by absorption, partly by irregular deposit on its articulating surface;
sometimes also it is studded by the porcellanous formation.
Practically, the occurrence of such change becomes of the greatest
importance. For example, suppose that an elderly man sustains con-
tusion of the hip by a fall, and is taken up lame. Fracture of the hip-
joint is naturally suspected; but on a very careful examination, the
usual signs of this form of injury are found Avholly wanting, and the sur-
geon is satisfied that the case is one of mere bruise only. The treatment
is conducted accordingly. The attendant unaware of such change, in
the relation of the head and neck of the bone to the shaft, being likely to
occur, has not protected himself by his prognosis, and never thought of
ON LOOSE CARTILAGE IN THE JOINT.
309
fore-warning the patient and his friends, that by the occurrence of such
change, the more prominent symptoms of fracture may by and bye be
closely simulated. After three or four Aveeks of confinement on account
of the results of the bruise—for in the aged such time is not unfrequently
required for disappearance of the pain and lameness—the patient gets
up, and attempts to walk ; and then, for the first time, is noticed a
shortening of the limb, Avhich may vary from less than half to considera-
bly beyond a full inch. The surgeon is surprised, and the patient is
mortified, perhaps indignant; being naturally led to suppose that his
case has been mistaken, and consequently mismanaged ; that Avhat Avas
called and treated as a bruise, Avas after all a fracture. Whereas, had
not only the possibility but the probability of such a change been both
knoAvn and remembered, all Avould have been rightly understood and
patiently submitted to ; both the feelings of the patient and his friends,
and the reputation of the surgeon, would have been uninjured.
Loose Cartilage (7) in the Joint.
Loose substances, usually of an irregularly oval form, are sometimes
found loose Avithin the cavity of articulations ; and the joint by far the
most liable to this affection is the knee. They are commonly termed '
cartilages ; but according to Miiller, this is a misnomer ; their con-
sistence being that of cartilage, but their structure distinctly fibrous.
Sometimes they are of almost calcareous or osseous density. They vary
in size from that of a pea to that of a prune ; the average dimensions
are those of a flattened middle-sized bean. The surface is generally
smooth ; but sometimes broken by slight nodosities. Most frequently
they occur singly ; and seldom more than two or three are found in any
one joint.
It is probable that in three Avays these substances may be produced.
1. By external growth. A fibrinous deposit takes place exterior to the
synovial membrane ; and as it enlarges, that membrane is pushed before
it forming a close envelope. The little mass projects into the cavity of
the joint, and is not unlikely to assume a pedunculated character. On
a sudden movement, the peduncle may be severed, and the extraneous
substance is thrown loose into the joint. 2. By internal formation, in
the substance of the synovial membrane. A fibrinous mass may form
in that tissue, analogous to the adventitious structures found in the
"fimbriated" condition of the synovial apparatus, formerly described ;
but differing from such formations in being single, instead of gregarious ;
and ultimately becoming much more dense in structure. It is not diffi-
cult to imagine how such a formation, at first attached, may become
separate, and float loose within the cavity. 3. By hypertrophy of the
original cartilage. Joints—especially those of the elbow and knee—
are not unfrequently found in Museums with marked and irregular
enlargement of their cartilage, and also, in some degree, of the subjacent
bone, at the outer rim of the cartilaginous surface ; part of these
excrescences may point towards the joint, showing more or less of the
pedunculated form ; portions may be found within the joint, some quite
loose, and others yet adherent. Such preparations sufficiently indicate
310
PRINCIPLES OF SURGERY.
the anormal process Avhereby this third mode of formation may be
effected. It should also be observed, hoAvever, that such enlargement
is not mere hypertrophy of the original cartilage ; the texture is changed,
becoming infinitely more dense and fibrinous ; and it is a portion of this
so altered tissue Avhich is projected and detached.
HoAvever occasioned, the symptoms are usually sufficiently distinct.
At times there is no uneasiness ; the foreign body remaining in a part
of the joint removed from the play of the bones in progression. Sud-
denly, however, it may become dislodged from this retreat; and, coming
betAveen the ends of the bones, on an instant the most excruciating pain
is endured ; the limb is rendered rigid, and motion arrested, as if by a
spell. And the distressing symptoms are not relieved, until by gentle
flexion and manipulation, the intruding substance has been again placed
in its unoffending position. Such occurrences, by frequent repetition,
are themselves a source of much inconvenience and discomfort; and
besides, they are not unlikely to prove the means of lighting up an
inflammatory action, Avhereby the most serious consequences may ensue.
It becomes an object of some importance, therefore, either to palliate
the symptoms, or by removal of their cause, to dispel them quite.
Treatment.—When inconvenience is not much complained of—only
occasional, then not very severe, and remedied with tolerable facility-
treatment should be but palliative. For, operation is scarcely war-
ranted ; and puncture of such an important articulation as the knee is
never Avholly free from risk, hoAvever skilfully and carefully conducted.
Furthermore, experience has fully proved that any operation, sakelessly
although Avell performed, has an especial tendency towards an untoward
issue. An elastic bandage, or tightly fitting knee-cap, is applied, and
constantly worn ; with the vieAv of limiting the redundant body within
its own domain—where remaining, it proves inoffensive. Should it
accidentally escape, and become jammed between the head of the tibia
and condyles of the femur, it is to be instantly replaced, and the appa-
ratus resumed as before ; and recumbency is advisable for a feAv hours
afterwards, in order that all local excitement may wholly pass aAvay.
Not unfrequently, however, palliation fails ; the patient's life is ren-
dered miserable, and himself unfit for active occupation ; also organic
disease may bo threatened by the oft-repeated excitement. In such
cases, the patient may urgently demand removal of the offending sub-
stance by operation ; and fortunately, his request may be noAV-a-days
agreed to, with a very fair prospect of success ; the subcutaneous and
valvular mode of puncture being adopted; the adaptation of which
form of wound, to such cases, seem to have occurred simultaneously
to two surgeons, Messrs. Syme and Goyrand.* In the first place, the
patient is to be prepared for the operation. For a day or two the limb
is to be disused, so that previous excitement may have thoroughly sub-
sided ; Ioav diet is enjoined, the primae viae are gently yet efficiently
cleared, and general secretion is seen to be in a satisfactory state, so
that there may be no predisposition to inflammation. Then the foreign
* I am informed by my colleague, Dr. Duncan, that about the same time he also
contemplated the subcutaneous operation in this affection.
ON LOOSE CARTILAGES IN THE JOINT.
311
body, having been made superficial, is gently pushed to the extreme
verge of the synovial pouch, either on the inside or on the outside of
the patella, as may be most convenient—the internal position is usually
the preferable—and there retained fixedly by the fingers of an attentive
and steady assistant. A tenotomy needle, or thin and narrow bistoury,
of a fine edge, is passed in an oblique direction; and an incision, a
little larger than the outline of the cartilage, is made through the tense
synovial membrane. The instrument is then AvithdraAvn sloAvly and
cautiously, the finger gently yet firmly following on and consolidating
its track; a feAv drops of blood escape, but not a particle of synovia;
and no air has obtained admission, even to the cellular tissue. The
intevay under a combination of
the two. 1. The patient's age is an important point in such delibera-
tion. For resection,, he should be neither very young nor very old ; if
young, scrofula is likely to be much concerned in the disease—and not
ON ANCHYLOSIS.
315
of a quiet but of an acute, and as it were restlessly active, kind ; if old,
there may be Avant of restorative energy in the Avound. 2. The system
should not be much exhausted ; otherwise, not only is the re-induction
of disease favoured, by Avant of power, both locally and generally ; but
also it may happen that the suppuration in the Avound continues to prove
excessive, unaccompanied by efficient effort at reparation, and removal
of the hectic cause by amputation may be imperatively demanded. The
certainty of suppuration, profuse and perhaps protracted, and the chance
of amputation following thereon, should never be omitted in our prog-
nostic calculations. 3. By careful examination Avith the probe, and by
manipulation, Ave should be satisfied that the disease is truly of no great
extent beyond the mere articular extremities ; for it is plain, that the
removal of several inches of each bone—and unless all the diseased
part be thoroughly taken aAvay, the operation had better be unattempted
—cannot be expected to be followed by even an approach to a cure in
any Avay satisfactory, and ought to be superseded by the not more ruth-
less procedure of amputation. Regarding extensive involvement of the
soft parts, we need be less anxious; they being capable of recovery
under apparently very adverse circumstances, as already stated. 4.
Finally, the more intense the development of the scrofulous diathesis,
the more unfavourable the case for resection; and vice versa.
Anchylosis.
Stiffness of a joint, as can be readily understood from Avhat has been
stated, may depend on various conditions of the articulation and of the
parts exterior. Accordingly, anchylosis is said to be of different kinds.
1. Osseous or Complete.—This is the result of ulcer ; the osseous
texture having been exposed thereby, and subsequently becoming en-
gaged in an energetic effort towards reparation; the neAV osseous for-
mation proves excessive, and the opposing bones become firmly united
by incorporation. Or the anchylosis may be in a great measure inde-
pendent of change in the interior, depending mainly on exuberant ossi-
fication on the external aspect; the joint becoming immoveably locked
in the tight embrace of an outer case of bone, continuous and incorpo-
rated with the original tissue ; the result of a chronic perversion of vas-
cular action, of a Ioav grade, and probably connected with rheumatism.
Or both forms may be combined, the anchylosis being general and at
every point complete ; and almost all traces of previous articulation
having become effaced.
2. Ligamentous.—The articular surfaces remain unincorporated at
any part; but are kept in close union, and more or less immoveable,
by alteration in the ligamentous apparatus exterior, which has become
condensed, rigid, and non-elastic.
3. In the Spurious Anchylosis, there is neither amalgamation of the
bones, nor much, if any, structural change of the proper ligaments of
the joint; but fibrinous deposit has occurred extensively, exterior^ to
both ; the flexor muscles and tendons have become contracted and rigid ;
and from this cause motion is more or less impaired. This state may
316
PRINCIPLES OF SURGERY.
or may not be conjoined with synovial disease within the articulation ;
usually it is. ,
Treatment of Anchylosis.—In all cases, anchylosis should be most
warily interfered Avith ; for it may be regarded as a compromise between
health and disease—an imperfect cure, yet both a saving of the part
and a cessation of morbid action—the rash infringement of which is
most likely to be visited by untOAvard consequences. The true form is
plainly not to be broken up, either by gentle or by violent means. The
latter have been made trial of, with a result truly deplorable. A cer-
tain M. Louvrier invented an apparatus, by the rude force of which
stiff joints Avere instantaneously straightened ; and patients were sub-
mitted to the torture of this " infernal machine." ^ A few escaped with
comparative impunity, yet with little improvement in the part; in others,
laceration, suppuration, gangrene, delirium Avere the results—" acci-
dents frightfully severe, and ordinarily folloAved by death."* The Only
means of treatment to Avhich anchylosis is amenable, is that formerly
noticed, by section exterior to the obliterated joint and formation of a
false joint thereby; an operation which has been successfully applied
to both the hip and knee joints, but in regard to the expediency of
which we desiderate a larger experience.
Fortunately the true form of anchylosis is that which most rarely
occurs ; a joint may seem to be rigidly immoveable, and that by ossi-
fication, yet may be altogether free from that form of structural change,
and quite capable of a resumed, though it may be diminished, func-
tion—an example of either of the tAvo other forms of the affection.
Both of these admit of cure ; in many cases function may be Avholly
restored ; in others the restoration is never complete. In no case should
it be attempted, till all active disease has wholly subsided Avithin the
joint; and even then, the process of cure should invariably be Avarily
and gradually conducted, lest re-accession of disease ensue. The
means of restoration are :—passive motion, frequently employed with
all gentleness, and always regulated by the sensations of the patient;
friction, Avith embrocations of a stimulant nature, especially over the
extensor muscles ; local steam bath ; shampooing ; and, if need be, the
division, by subcutaneous section, of the rigid flexor tendons. Splints,
bandaging, and other mechanical means, are also often of service, in
restoring normal position of the joint, not suddenly but sloAvly and with
much caution; and this aid is especially necessary in those cases, by
no means few, in Avhich there is not merely flexion of the joint to be
undone, but rotation also. Thus, in the knee, as already stated, flexion
is seldom great, Avithout rotation outAvards of the head of the tibia ; and
unless this be rectified—as can only be done by mechanical means—
the cure is obviously incomplete. When tenotomy has been employed,
the restorative measures by friction, motion, and machinery, ought
never to be had recourse to until the punctures have fairly healed—a
few days usually suffice ; otherwise inflammation and suppuration might
readily be induced.
The propriety may be here again urged of attention to the position of
* British and Foreign Medical Review. No. 24, p. 552.
ON NEURALGIA OF JOINTS.
317
the joint, in those cases in which the occurrence of complete and irre-
mediable anchylosis is expected ; in order that the rigid member may
possess its maximum of usefulness.
Neuralgia of Joints.
Affections of joints, dependent on inflammatory action and the struc-
tural changes thereby induced, are the most frequent in occurrence.
We are, however, not without examples of local irritation, in which
perverted vascular action is almost wholly in abeyance. The prominent
characteristic is pain, unaccompanied by swelling, or other indication
of structural change. The affection may be either primary, constituting
a disease per se ; or it may be secondary, merely a symptom of an ear-
lier and more grave disorder. In the knee, for example, we may have
nervous pain, either as a symptom of morbus coxarius, or a truly neu-
ralgic affection of that part, independent of disease elseAvhere—although,
indeed, the last observation must be made Avith some reservation, in-
asmuch as there are found but feAv cases of neuralgia, in that or any
other joint, which are not more or less connected with a perverted
state, as to structure, function, or both, in some of the internal organs.
Neuralgic affection of the joints is characterized by a class of symp-
toms sufficiently distinct; a circumstance of much importance, inasmuch
as the appropriate treatment is very different from that Avhich is de-
manded for structural change. The pain has the ordinary character of
the nervous ; remittent, intermittent, not slowly and steadily increasing,
not constant, not increased by pressure, and not limited to one part,
but diffused over the Avhole of a wide extent of surface. The patient's
mind may be diverted from the uneasiness, by conversation, or other-
wise engaging the attention; and while the mind is so occupied, the
pain is really absent. There is no SAvelling ; at least if there be, it is
but trivial in all respects ; a mere puffiness, by oedema of the surface;
not at all resembling Avhat folloAvs inflammatory action in any of the
textures of the joint. Motion is well borne ; and so is manipulation,
even rude; the uneasy sensations are not increased by cither. The
joint itself may be jarred, pressed, jerked Avith impunity; Avhereas much
complaint may folloAV a pinching of the super-imposed integument; that
texture sometimes seeming to be of greatly increased sensibility. There
is no flexion of the joint, as in serious structural change ; on the con-
trary, the limb will most frequently be found extended. The spasms
too are wanting, Avhich so frequently attend and invariably aggravate
acute vascular disease. The patient is obviously out of health ; and
labours under irritation, general as well as local; but the system is un-
involved in either inflammatory or hectic fever.
This affection more frequently occurs in females than in males. And
usually the symptoms will be found at least connected^if not caused,
by disorder of an internal organ ; hysteria; dyspepsia; irritation of the
bowels, by Avorms, or by lodgement of other noxious matter. In chil-
dren, some affections of the joints, apparently neuralgic, Avould seem
to depend on the irritation of dentition.
The treatment of neuralgic joints is mainly directed towards the gene-
27*
318
PRINCIPLES OF SURGERY.
ral system ; restoring normal functions to the uterus, stomach, and in-
testines, as the circumstances of the case may require. The local
applications need be but simple. The serious treatment for structural
change Avould here be not only unnecessary, but certain to prove in-
jurious. The endermoid use of nitrate silver, so as merely to blacken
the surface, is on the whole the preferable application ; it not only is
really efficient towards mitigation of the neuralgy, but also, having an
imposing character in the eyes of the patient, is useful by satisfying the
mental anxiety, which ahvays attends, and sometimes is not the least
prominent of the symptoms. Medicated friction or fomentation may
also prove of service in a similar manner. But every stimulus, at all
powerful, should be either abstained from, or most cautiously used;
inasmuch as the morbid condition of the nervous system of the part may
here, as elseAvhere, prove but a stepping-stone toAvards the accession
of inflammatory action, entailing serious structural change.
The vital importance of a careful diagnosis need not be insisted on.
Lest, on the one hand, wTe treat with unwarrantable severity a com-
paratively trifling disorder ; and, on the other hand, lest Ave commit the
greater error, of supposing a really formidable change of structure in
bone, cartilage, or synovial membrane, to be but a nervous affection,
and discover not our error until loss of texture and function has become
not only great but wholly irremediable.
Wounds of Joints.
Wounds penetrating into the more important joints, are invariably
to be regarded as among the gravest of injuries; and the danger is by
inflammation of the synovial membrane. To either the aversion or
mitigation of this, treatment is to be directed.
The signs of the accident are not indistinct. The nature of the
weapon; the manner and degree of force with which it was applied;
the extent, position, and form of the Avound ; the trickling of synovia,
in the form of oily globules, along with the immediate serous discharge
which the wound affords; the presence of a shock to the general ner-
vous system, more or less intense—these, in the great majority of cases,
are sufficiently plain indications of the joint having been opened into.
It is wholly unnecessary to use either the probe or finger, in explora-
tion. Meddlesome surgery is never good; in no case is it more de-
cidedly bad than here. Many a joint may, under suitable treatment,
resist the original injury successfully ; but feAv are able to escape, with
impunity, from wound followed by rude, unskilful, unnecessary explora-
tion. The probe and finger are not used here; the eye, aided by the
lightest touch, is sufficient.
When the wound is of the lacerated or bruised kind, inflammation is
inevitable. The track of the wound can heal only by granulation,
which is invariably preceded by inflammation ; and inflammation of one
part of the synovial membrane may scarcely be restrained from over-
spreading the whole. All that is in our power, under such circum-
stances, therefore, is to mitigate what we cannot avert; to keep the
action of a low grade, and save change of structure. When the wound
ON AFFECTIONS OF BURS.E.
319
is simple and incised, however, the object of our treatment is altogether
prophylactic. By absolute rest, rigid antiphlogistic regimen, and the
continued application of cold, during the period of incubation; by loss
of blood, general and local, timeous and plentiful, as soon as inflamma-
tion threatens to supervene ; by calomel and opium, antimony, or other
selection from the more powerful antiphlogistic remedies—we avert
the true inflammatory crisis from both the interior of the joint and the
wound's track, so obtaining for the latter union by adhesion. In fa-
vour of this result, disuse of suture is advisable ; approximation beino-
intrusted to plaster and position; and by that mode of dressing, also,
another important indication may be fulfilled—exclusion of atmospheric
influence. The wound, however, may be so extensive as to demand
the aid of suture for its coaptation ; in this case the stitches should be
as few as possible, and especial care should be taken that they inclose
skin alone; the deeper part of the wound's track, and more especially
the synovial membrane, remaining untouched.
When inflammation with suppuration of the synovial membrane has
occurred—as will sometimes be the case notwithstanding our best
care—more or less structural change occurs in that texture ; it becomes
thickened, infiltrated, and coated by fibrinous exudation ; at some parts
it may be broken by ulceration. Ruin of cartilage and bone is not
unlikely to follow. Such cases are to be treated on the principles,
already inculcated, for similar diseased action of non-traumatic origin.
The symptoms are certain to prove most urgent. The inflammatory
fever will be of the gravest kind ; and, in addition to its ordinary signs,
great irritability of the stomach is often both prominent and distressing ;
the swelling, pain, and discbarge, will be proportionally great. Yet
something like resolution may be effected; all may become quiet, and
the joint may recover not only its form, but almost its pristine motion.
Or it stiffens, by anchylosis, perhaps irremediably ; change of structure
having gone so far as to leave no hope of cure, unless by copious plastic
exudation from the exposed bone. Or hectic becomes paramount, ere
yet destruction of texture has ceased in the joint; and then, to save
life, we must sacrifice the limb.
AFFECTIONS OF BURSJG.
Bursas are lined by a delicate membrane ; very similar, both in health
and in disease, to the synovial investiture of joints. They are of two
kinds; the majority being of original and normal formation ; a feAv, ad-
ventitious, the res